Scientific Research Journal of India (SRJI), Vol 2, Issue 3, Year 2013 by Dr. Krishna N. Sharma

Scientific Research Journal of India (Multidisciplinary, Peer Reviewed, Open Access, Journal of science) ISSN: 2277-1700 Vol: 2, Issue: 3, Year: 2013

Editor in Chief Dr. Krishna N. Sharma (PT) Editors Dr. Popiha Bordoloi Dr. Kuki Bordoloi Dr. Sudeep Kale Dr. Waqar Naqvi Junior Editor Mrityunjay Sharma

Office Dr. L. Sharma Campus, Muhammadabad Gohna, Mau, U.P., India. Pin- 276403 Website http://srji.drkrishna.co.in URL Forwarded to http://sites.google.com/site/scientificrji Email editor.srji@gmail.com Contact +91-9320699167

Declaration: The contents of the articles and the views expressed therein are the sole responsibility of the authors, and the editorial board will not be held responsible for the same. Copyright ÂŠ 2013 Scientific Research Journal of India All rights reserved.

CONTENTS

Effect

Title

Author/s

Editorial

Dr. Krishna N. Sharma

core

Department

Page i

stabilization

training on endurance of trunk extensor and functional capacity in subjects with mechanical low

Ranjeet Kumar, Dr. Prosenjit Patra

Physiotherapy

back pain Effect

trunk

muscles

stabilization exercises and general exercises on disability in recurrent non specific low back ache

Kumar Amit, Gupta Manish, Kumar Satish, Katyal Taruna

Study of respiratory capacity and

Shweta S. Devare Phadke,

core muscle strength in Indian

Sukhada Prabhu, Sujata

classical singers Aerobic

capacity,

Yardi body

mass

index and fat fold measurements

Sharma Chetan, Dr. Dar

of healthy athletes in Dehradun â&#x20AC;&#x201C;

Shahid Mohd.

A cross sectional study Effects of bimanual functional practice training on functional

Dr Jasmine Anandabai,

performance of upper extremity in

Dr Manish Gupta

chronic stroke A comparison study on physical impairments

and

functional

limitations of patients: 1 year after

Amit Murli Patel

total knee arthroplasty versus control subjects Respiratory

physiotherapy

Shanmuga Raju P,

triple vessel disease with post

Renkha Rao, Rajendhra

coronary artery bypass grafting

Kumar J, SuryaNaryana

surgery (CABG)

Reddy V

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Occupational therapy marketing indian prospective Annotated bibliography of studies w.r.t statistical methods

Koushik Sau

Occupational Therapy

Neha Dewan

Physiotherapy

EDITORIAL

Dear Readers! I am very pleased to present this issue of the Scientific Research Journal of India (SRJI). With this issue. This issue of the multidisciplinary and open access Journal of science contains total 8 papers in Physiotherapy, and 1 paper in Occupational Therapy. I hope youâ&#x20AC;&#x2122;ll find these papers informative.

Here I would like to bring one more thing to your notice that new and permanent URL is http://SRJI.DrKrishna.co.in and it will be directed to http://sites.google.com/site/scientificrji .

Do drop a mail to us (editor.srji@gmail.com) if you have any comment and suggestion.

Happy Reading.

Regards,

Dr. Krishna N. Sharma Editor in Chief

EFFECT OF CORE STABILIZATION TRAINING ON ENDURANCE OF TRUNK EXTENSOR AND FUNCTIONAL CAPACITY IN SUBJECTS WITH MECHANICAL LOW BACK PAIN Ranjeet Kumar, MPT (Musculoskeletal Disorder)*, Dr. Prosenjit Patra, MPT (Cardiopulmonary)**

ABSTRACT STUDY OBJECTIVES: To determine the effect of Core stabilization training on trunk extensor endurance and functional capacity in subjects with mechanical low back pain. DESIGN: Experimental study. SETTING: All the Subjects were taken from Dolphin (PG) Institute Of Biomedical and Natural Science, Dehradun and the community in and community in and around Dehradun. SUBJECTS: A total of 30 subjects (M: 14, F: 16) were recruited for the study on the basis of inclusion and exclusion criteria after signing the informed consent form. METHODS: A total of 30 subjects (M: 14, F: 16) were recruited for the study on the basis of inclusion and exclusion criteria after signing the informed consent form. The subjects were then divided into two groups, (Group A= Core Stabilization and Endurance Training & Group B= Endurance Training). All the subjects were asked to perform 5 min warm-up exercise before the intervention. The total duration of the protocol was 6 weeks and frequency of exercise performed is 3 times per weeks. OUTCOME MEASURE: Trunk Extensor Endurance Test was measured using Prone Double Straight-Leg Raise Test, & Functional Capacity was assessed using Modified Oswestry Disability Index. RESULTS: The result of the study demonstrates that both the Groups showed significant improvement when comparison is made within the groups with p=0.001 for both trunk extensor endurance test and functional capacity. However, Group A shows significant improvement between the groups post intervention p=0.023 & p=.000 respectively. 1

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CONCLUSION: From the present study it can be concluded that core stabilization training is effective in increasing trunk extensor endurance and functional capacity in subjects with mechanical low back pain.

KEY WORDS: Core stabilization training, Endurance training, Trunk extensor endurance, Mechanical low back pain, Trunk Extensor Endurance

extremities, which will increase the predisposition

INTRODUCTION

to chronic injuries.5 Low back pain is one of the most common

The core has been described as a box with

and costly musculo-skeletal pain syndromes,

the abdominals in the front, paraspinal and gluteals

affecting up to 80% of people at some point during

in the back, the diaphragm as the roof and the

their lifetime. The re-occurrence rate of low back

pelvic floor and hip girdle musculature as the

pain is high and these disorders often develop into

bottom. Therefore, the core serves as a muscular

a chronic fluctuating problem with intermittent

corset that works as a unit to stabilize the body and

flares.6

spine.1 Caring for chronic low back pain, is one of

Panjabi

the most difficult and unrewarding problems in

subsystem,

clearly definitive or effective. One possible

vertebra

facet

skeletal subsystem consists of muscles and tendons

respond to a specific treatment approach.6 For most

that surround the spinal column. The neural and

patients with acute low back pain, the etiology is

feedback subsystem consists of various force and

thought to be a mechanical cause involving the

motion transducers located in ligaments, tendons,

spine and surrounding structures.12 A wide range

muscles and neural control centers. These passive,

of terms is used for non-specific mechanical

active and neural control subsystems - although

causes, including low back strain/sprain, facet joint

conceptually

segmental

separate

are

functionally

independent. The passive subsystem does not

dysfunction, somatic dysfunction, ligamentous

provide any significant stability to the spine in the

strain and myofascial strain.3

vicinity of the neutral position. It is towards the

Biomechanics may be altered due to low

ends of the ranges of motion that the ligaments

back pain or injury to the spine, producing

develop reactive forces that resist spinal motion.

weakness and loss of muscle control, which leads

The active subsystem is the means through which

to further injury because the joints are not

the spinal stabilization system generates forces and

appropriately supported again, this may result in the

includes

properties of the muscles. The active muscular

defining groups of patients who are most likely to

which

joint capsules, as well as the passive mechanical

treatment protocols is the lack of success in

over-compensation

spinal

orientation, intervertebral disc, spinal ligament and

explanation for the inability to identify effective

syndrome,

the

of three subsystems; passive muscular skeletal

any form of treatment, has been shown to be

sacroiliac

describe

stabilization system is conceptualized as consisting

clinical medicine, as no approach to diagnose or

syndrome,

(1992)

pelvis

provides the required stability to the spine. The

lower 2

Scientific Research Journal of India â&#x2014;? Volume: 2, Issue: 3, Year: 2013

magnitude of the force generated in each muscle is

pain intensity, alleviate functional disability and

measured

improve core stability and back extension strength,

the

force

transducers

(signal

mobility and endurance.17

producing devices) located in the tendons of the muscles.15

According to Chok et al. (1999), poor

Therefore, this aspect of the tendons may

endurance of the trunk muscles may induce strain

be part of the neural control subsystem. Within the

on the passive structures of the lumbar spine,

neutral zone of motion, (that part of the range of

eventually leading to low back pain. Evidence

physiological intervertebral motion, measured

suggests that muscle endurance is lower for people

from the normal position, within which the spinal

with low back pain than for individuals without

motion is produced with a minimal internal

low back pain. Due to endurance being less in

resistance - it is the region of high flexibility

trunk muscles, fatigue can affect the ability of

around the mid-zone of motion) the restraints and

people with low back pain to respond to the

control for bending, rotating and shear force are

demands of an unexpected load. Fatigue, after

largely provided by the muscles that surround and

repetitive loading, also leads to loss of control and

act on the spinal segment. The neural subsystem

precision, which may predispose an individual to

receives information from the various transducers,

developing low back pain. Therefore, trunk muscle

determines

endurance training has been recommended to

specific

requirements

for

spinal

stability and causes the active subsystem to

elevate

fatigue

threshold

and

improve

achieve the stability goal.16

performance, thus, reducing disability of the lumbar spine.4

Well-developed core stability allows for improved force output, increased neuromuscular

Endurance training of back extensor

efficiency and a decrease in the incidence of

muscles, including the multifidus, has long been

overuse injuries.9 The normal function of the

recognized as a crucial preventative of recurrent

stabilization system is to provide sufficient

low back pain. The function and coordination of

stability to the spine to match instantaneous

the muscles that stabilize the lumbar spine,

varying stability demands made by changes in

especially the lumbar extensor muscles, are often

spinal posture, static and dynamic load.15 Hicks et

impaired in patients with low back pain.13

al, suggest that core stability system has a role in

The role of trunk stabilizers is to retain the

ensuring spinal stability and according to van

musculature; to control, coordinate and optimize

Dillin et al. (2001), a decrease in spinal stability

function. Trunk fatigue, which occurs during

places stress and excessive load on the spinal

intense training or matches, produces a loss in

joints and tissues, which eventually results in low

synchrony between upper and lower extremities,

back pain.

which may cause a reduction in muscle strength.

Control of back pain and prevention of its

This may in turn prevent a proper transfer of force

occurrence can be assisted by enhancing muscle

resulting in inappropriate compensation by the

control of the spinal segment through core stability

body while performing a particular function.5

exercises. Therefore, exercise programs, which are

Dynamic trunk stability training includes

based on active rehabilitation, can reduce low back

building muscle strength, endurance and using

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○ Rest-1minute

neuromuscular control to maintain dynamic trunk stability.

METHODOLOGY An experimental study was conducted on 30 subjects (14 male and 16 female) who were recruited Biomedical

from and

Dolphin

(PG)

Natural

Institute

Science

and

of the

3. Abdominal crunch

community in and around Dehradun based on the

o Sets-2

inclusion and exclusion criteria and they were

o Repetition-8

divided into two groups after informed consent

o Rest-1minute

was obtained. Group A (Core Stabilization and Endurance Training) & Group B (Endurance Training). Pre intervention measurement of Trunk Extensor Endurance Test was measured using Prone Double Straight2-Leg Raise Test, & Functional Capacity was assessed using Modified Oswestry Disability Index8. For both the groups 5

4. Supine Russian twist

min of warm exercise was given before the

o Sets-2

intervention. The total duration of protocol was 6

o Repetition-8

weeks and frequency of exercise was 3 times per

o Rest-1minute

week. Protocol for Group A: All subjects in this group received Core stabilization training and Endurance training on a Swiss ball. 1. Lunge ○ Sets-2

Protocol for Group B: All subjects in this group

○ Repetition-8

received Endurance training on a Swiss ball. 1. Bilateral shoulder lifts

○ Rest-1minute

○ Sets-6 ○ Repeatation-5 ○ Rest-1 minute ○ Holding-20sec

2. Supine lateral roll. ○ Sets-2 ○ Repetition-8 4

Scientific Research Journal of India â&#x2014;? Volume: 2, Issue: 3, Year: 2013

2. Contra-lateral arm and leg lifts

t-test was used for data analysis within the group

o Sets-2

A and group B for Extensor muscle endurance test

o Repeatation-8

and Modified Oswestry Low Back Pain Disability

o Rest-1 minute

Index. Independent t-test was used for data

o Holding-20sec

analysis between the group A and group B for Modified Oswestry Low Back Pain Disability Index. The p value was set at (<0.05). RESULTS Data was analysed for 30 participants: 15 in each Group A & Group B.

Bilateral shoulder lifts with hands behind the head

Table1.1: Comparison of mean value for age

o Sets-2

between group A and B

o Repeatation-8 o Rest-1 minute o Holding-20sec

4. Bilateral shoulder lifts with arms in

Table 1.2: Comparison of Pre and Post EET score

full elevation

for group A and group B

o Sets-2 o Repeatation-8 o Rest-1 minute o Holding-20sec

Table1.3: Comparison of Pre and Post MODI score for group A and group B

DATA ANALYSIS Data was analysed using statistical package of social sciences SPSS software (version 14.0). Pair

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Table 1.4: Comparison of Pre and Post EET score

given Core stabilization training and Endurance

between group A and group B

training on a Swiss ball and Group B was given Endurance training on a Swiss ball. Both groups received training three times a week for six weeks. The changes observed in this study were noteworthy. Within group comparison showed significant changes with improvement in isometric

Table 1.5: Comparison of Pre and Post MODI

hold time and functional capacity in both groups A

score between group A and group B

and B. In between groups, statistically significance difference was found in isometric hold time and functional capacity. According to Moffroid, Progression of loading

through

postural

changes

produces

increases in endurance time of the back extensors, as measured by the Sorensen Test. These postural progressions increase the load moment on the spine and thereby stress the erector spinae

Results of the study showed that there is

muscles, multifidus and others.14

improvement in trunk extensor endurance and

In addition adoptive changes occur in

functional capacity after the intervention in both pressure

skeletal muscle during endurance training ie,

threshold was found to be statistically significant.

slower rate of glycogenolysis, slower rate of

Group A (Trunk Extensor Endurance & Core

lactate production during submaximal exercise

Stabilization) showed more improvement when

occurs due to raise in the lactate threshold both in

compared to Group A and this was found to be

absolute and relatives terms ie, o2 uptake(VO2)at

statistically significant with p=0.023 & p=.000

LT and vo2 max at LT, increased mitochondrial

respectively.

enzyme activity and increase capillary density.7

the

groups.

This

improvement

Therefore, it is reasonable to expect increased endurance of trunk extensor muscle in

DISCUSSION

group B subjects who only underwent endurance

The present study investigated the effect

training.

of core stabilization training on endurance of trunk extensor and functional capacity in subjects with

Core stabilization training has a theoretical

mechanical low back pain. Endurance of Trunk

basis in treatment and prevention of various

extensor and functional capacity was measured 2

musculoskeletal conditions.

post-intervention

Core stabilization training is hypothesized

through prone double straight leg raise test and

to increase muscle activation by increasing motor

Modified Oswestry Low Back Pain Disability

unit recruitment, rate and synchronization of

Index respectively. Subjects were divided into two

firing11

times:

pre-intervention

and

groups as Group A and Group B. Group A was

Scientific Research Journal of India â&#x2014;? Volume: 2, Issue: 3, Year: 2013

Richardson found that individual with low

stabilize their form better during performance of

back pain exhibits delayed activation of the

prone double leg raise test, thereby resulting in

transversus abdominis muscle when compared

longer hold times than subjects who only

with normal individual. Low back pain patient

underwent endurance training.18

have an impaired ability to consciously contract

So over all core stabilization training

transversus abdominis and this is an important

increases

component of abdominal stability training.17

abdominus,

Performance of exercises on unstable

muscle lumbar

activation

(transversus

multifidus),

alters

neuromuscular control and also increases spinal

surfaces like Swiss ball has been shown to increase

stability, leading to decreased pain which

the activity of the rectus abdominis. It also causes

have led to the increased isometric hold time and

changes in muscle activity and force output and

functional capacity in group A subjects as

may be another way of potentially altering

compared to subjects in group B.

neuromuscular recruitment pattern

may

Limitation of the study are sample size

Spinal instability occurs generally as a

was limited and no blinding was done during the

result of delayed recruitment of core muscle/local

study. So the further recommendation for future

muscle like transversus abdominus, multifidus and

studies need to be done with broader dimensions,

core stabilization training address these core

EMG could be used to quantify the activation of

muscle, thereby increase spinal stability.

core muscle and it can also be used to track global

Study by Kimitake Satoand Monique

muscle activation during core stability testing.

Mokha has shown that core stabilization training

Bio-mechanical marker can be measured.

let to an increase in 5000meter run time performance. The proposed mechanism was that

CONCLUSION

subjects who underwent core stabilization were From the present study it can be concluded that

conscious of using their core muscle to stabilize

core stabilization training is effective in increasing

their running form. A similar mechanism may

trunk extensor endurance and functional capacity

exist in our study where by subjects who

in subjects with mechanical low back pain.

underwent core stabilization training were able to

REFERENCES

1. Akuthota V. and Nadler, S.F. Core Strengthening. Physical Medicine and Rehabilitation. 2004; 85(1): 86-92. 2. Arab A M, SalawatiMahyar, Mohhammad E. Sensitivity, specificity and predictive value of the clinical trunk muscle endurance tests in low back pain. Clinical Rehabilitation. 2007;21:640-647 3. Atlas, S.J. and Deyo, R.A. Evaluating and Managing Acute Low Back Pain in the Primary Care Setting. Journal of General Internal Medicine. 2001; 16(2): 120-131. 4. Chok, B., Raymond. L., Latimer, J. and SeangBeng, T. Endurance Training of the Trunk Extensor Muscles in People With Sub Acute Low Back Pain. Physical Therapy. 1999; 79(11):1032-1042.

ISSN: 2277-1700 ● Website: http://srji.drkrishna.co.in ● URL Forwarded to: http://sites.google.com/site/scientificrji

5. Cholewicki, J. and McGills, S.M. Lumbar Posterior Ligament Involvement During Extremely Heavy Lifts Estimated from Fluroscopeic Measurement. Journal of Biomechanics. 1992; 25:17-28. 8) 6. Dankaerts, W., O’Sullivian, P.B., Straker, L.M, Burnett, A.F. and Skouen, J.S. The Inter- Examiner Reliability of a Classification Method for non- Specific Chronic Low Back Patients with Motor Control Impairment. Manual Therapy.2005; 2:1-12. 7. Edward F, Coyle H, Martin, Susan A, Bloomfield, Oliver H, Lowry, John O, Holloszy. Effects of detraining on response to submaximal exercises. J.Appl. Physiol.1985 59(3): 853-859 8. Fritz JM, Irrgang JJ. A Comparison of a Modified Oswestry Disability Questionnaire and the Quebec Back Pain Disability Scale. Phys Ther 2001; 81:776-788. 9. Hedrick, A. Training the Trunk for Improved Athletic Performance. Strength and Conditioning Journal. 2000; 22(3), 50-61. 10. Hubley-Kozey, C.L. and Vezina, M.J. Muscle Activation During Exercise to Improve Trunk Stability in Men With Low Back Pain. Journal of Physical Medicine and Rehabilitation. 2002; 83(8): 11001108 11. Kisner C, Colby LA. Therapeutic Exercise Foundations and Techniques. 5th ed.Philadelphia: F.A Davis Company; 2007. 12. Krismer, M. and van Tulder, M. Low Back Pain (non-specific). Journal of Biomechanics. 2007; 21(1): 79-91. 13. Liebenson, C. Spinal Stabilization Training: The Therapeutic Alternative to Weight Training. The Journal of Body Work and Movement Therapies. 1997; 1 (2): 87-90 14. Moffroid MT, Haugh LD, Haig AJ, et al. Endurance training of trunk extensor muscles. Phys Ther. 1993; 73:10 –17. 15. Panjabi, M.M. The stabilizing system of the spine, Part 1: Neutral zone and instability hypothesis. Journal of Spinal Disorder. 1992; 5(4) 383 – 389. 16. Panjabi, M.M. The stabilizing system of the spine, Part 2: Neutral zone and instability hypothesis. Journal of Spinal Disorders. 1992; 5(4): 390 – 397. 17. Richardson C.A. and Jull G.A. Muscle control-pain control. What exercise would you prescribe?.Manual Therapy. 1995; 1: 2-10. 18. Sato K, Mokha M Does core strength training influence Running kinetics, lower-extremity stability, And 5000-m performance in runners? Journal of Strength and Conditioning Research. 2009; 23(1):133-140 19. VanDillin, L.R., Sahrmann, S.A., Norton, B.J., Coldwall, C.A., Flemming, D., McDonell, M.K. and Bloom, N.J. Effect of Active Limb Movements on Symptoms in Patients with Low Back Pain. Journal of Orthopaedic and Sports Physical Therapy. 2001; 31 (8): 402-4144. 20. http://www.exercise-ball-exercises.com/list-free-exercise-ball-exercises.htm CORRESPONDENCE

** Asst. Prof. Dolphin (PG) Institute, Dehradun (UK) * Student Researcher, Dolphin (PG) Institute, Dehradun (UK) 8

EFFECT OF TRUNK MUSCLES STABILIZATION EXERCISES AND GENERAL EXERCISES ON DISABILITY IN RECURRENT NON SPECIFIC LOW BACK ACHE Kumar Amit*, Gupta Manish, Kumar Satish**, Katyal Taruna***

ABSTRACT OBJECTIVE: To study the Effect Of Trunk Muscles Stabilization Exercises And General Exercises On Disability In Recurrent Non Specific Low Back Ache. DESIGN: Pre-test and Post test control group design. SETTING: Inpatient and rehabilitation hospital. PARTICIPANTS: A total number of 80 patients with recurrent non specific low back pain are allocated randomly into 1 of 2 groups; control group received general

exercise

only

(n=40) and

experimental

group

received

specific

stabilization

(n=40)

INTERVENTION Both groups received 6 weeks exercise intervention with 30-40 min per session, thrice per week and written advice. Main Outcome Measures: A Rolland Morris low back disability questionnaire were used to measure disability. Outcomes were measured before and after intervention. RESULTS: The calculated t-values for the RMDQ showed a significant variation at p=0.00. It showed that there is fulfilled improvement in post test RMDQ values when compared to pretest ODQ values in both the groups. The mean improvements between the two groups of low back pain patients were tested for significance using student ttest. The calculated t-values for the RMDQ scale was significant at p=0.011. This shows that mean improvement in the group II that received core strengthening is higher when compared to the group I that received conventional exercise program. CONCLUSION: This study concludes that specific stabilization exercise is beneficial in reducing disability and improved function in chronic non specific low back pain.

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KEYWORDS: Exercise, Low Back Pain, Stabilization, muscle, pain, disability

exercise. A more recent study that compared

INTRODUCTION

stabilization exercise against 2 other general back Technological and organizational changes in

extensor exercise regiments in patients with

the industrial countries during last few decades

nonspecific chronic low back pain demonstrated

have markedly increased the number of jobs performed

Monotonous

and

positive

constrained

reducing disability in short term than specific

90% of the population at sometime during their

stabilization and general exercises in subjects with

lives. Out of these 30% develop chronic low back

recurrent nonspecific low back pain10 Though

pain. Chronic low back disability appears to be any

other

form

conventional back care exercises and stabilization

exercises are proved to be effective in chronic

incapacity1. Deep trunk muscles eg, transversus abdominis

and

multifidus

responsible

mechanical low back pain patients, no literature

for

comparing the effectiveness on each other were

maintaining the stability of the spine2. So

found which necessitated the present study to

strengthening of these muscle and their restoration

compare the outcome

should be effective in the management of persistent

LBP.Therapeutic

workouts

muscle

General exercise program can be improved in

industrialized countries affecting about 80% to

than

multifidus

general exercise approach9. A study found that a

Common musculoskeletal health problem in the

faster

for

crosssectional area increase in favor of one of the

postures. Low back pain is one of the most

increasing

results

of conventional and

stabilization exercises in in chronic non specific

for

low back pain.

superficial and the deep muscles seem to be effective in the treatment of CLBP3. Trunk

METHODOLOGY

muscles exercises activate the abdominal and

A total number of 80 subjects, with

paraspinal muscles as a whole and at a relatively high

contraction

randomized

level4.

controlled

There

trials

are

nonspecific low back pain, were recruited from the

many

physiotherapy department of Sir Ganga Ram

RCTS on the

Hospital, New Delhi, India. All the subjects to the

usefulness of classic trunk exercises5, 6, increasing

physical department were referred from orthopedic

attention recently has been paid to the preferential

outpatient after proper detailed assessment by an

retraining of the local stabilizing muscles of the

orthopaedician.

spine7, 8. No randomized control trial has done that

total

150

subjects

and

performed 120 subjects clinical evaluation by their

stabilization training is beneficial in a sample of

physician including radiograph images. 40 subjects

patients with sub acute or chronic nonspecific low

are dropped out and therefore sample consisted of

back pain using pain and disability as outcome.

80 subjects with nonspecific CLBP.

Two relevent randomized control trial have been conducted in specific subgroup of patients with

Inclusion criteria were:

low back pain7, 8. But, in these trial, the specific

1. Patients who had a history of recurrent

effect of the trunk stabilization exercise regiment

LBP (repeated episodes of pain in past

was not compare to general back and abdominal 10

Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013

year collectively lasting less than 6

exercise only flexion and extension exercise and

months),

group-II

received

specific

trunk

muscle

stabilization exercise . Functional disability were

2. Patients who have nonspecific nature of

assessed

pain

the

Rolland

morris

disability

3. Patients who are willing to participate in

questionnaires, were considered most appropriate

the exercise program and willing to travel

and yield reliable and valid data. Suitable patients

independently to the hospital from the

were

home10

questionnaires of the Rolland Morris low back

asked

complete

number

4. Mean age of subject is 30-50yr

pain disability questionnaire that were repeated

5. Both gender are included.

immediately and after 6 weeks. Interventions were conducted over 6 weeks duration and each class duration of 30-40 min for thrice per week for both

Exclusion criteria were:

groups. Common components of the 2 programs 1. Patients with previous spinal surgery

included Short wave diathermy given for 15

2. Patients who have signs and symptoms of

minutes to relieve pain.For Group-l, Simple classic

gross

spinal

diagnosis

instability of

exercises for extensor Paraspinals and flexor

radiological

spondylolysis

abdominals muscle groups were administrated

appendix. If subjects were able to progress each

spondylolisthesis

week to a new level, on graded exposure exercise

3. Patients who had red flags suggesting serious spinal pathology11.

principle, otherwise they remained at the same

4. Patients with cardio –pulmonary diseases

exercise level.The exercises were repeated at

5. Patients with tumor, infection and fracture

home, for a maximum of half an hour 3 times per

6. Patients with rheumatic and inflammatory

weeks, from the beginning of the program. For Group-II, exercises were instructed as previous

condition 7. Patients with disc disease

recommendation appendix. The first session was

8. Lumbar strain or sprain

given individually for subjects assigned to this

9. Lumbar canal stenosis

group and lasted 30-45 minute. Initially exercises

10. Bowel and bladder dysfunction

with low intensityfor local stabilizing muscles was initially

administered

with

movements

The patients were not aware of the theoretical

isometric and in minimally loading positions. The

basis of each of the exercise regimes but they were

holding time and the number of contractions were

briefed the study objective. All the subjects were

increased progressively in these positions up to 10

interviewed

clinical

contractions repetitions x 10 sec duration each 1st

physiotherapist of Sir Ganga Ram Hospital who

and 2nd week. To ensure correct activation of the

was unaware of their group. By using random

transverse abdominis muscle was to observe a

sampling method, the subjects with non specific

slight drawing in maneuvers of the lower part of

low back pain were assigned to 1 of 2 treatment

the anterior abdominal wall below the umbilical

groups. Group–I received general low back

level consistent with the action of this muscle.

and

examined

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Various tactile and pressure cues and auditory cues

between the two groups of low back pain patients

were given to the patient to enhance the

were tested for significance using student t- test.

contractions and to get maximum corrective

The calculated t-values for the RMDQ scale was

position and outcomes. Too much effort of initial

significant at p=0.011.

contraction

Integration

with

muscles

was

dynamic

discouraged.

function

through

Table No 1: Comparison of disability (Rolland

incorporation of the stabilizing muscles’ co-

Morris) within Control group.

contraction into light function tasks was advised next 4-6 weeks as soon as the specific pattern of co-activation was achieved in the minimally loading

position

and

the

subjects

could

comfortable performed 10 contraction repetition x 10 sec duration each. A senior clinical physical therapist assessed the outcome measures of this

The disability in the control group has

study. All subjects received an information booklet

decreased post intervention, as in shown by their

providing the latest scientific facts on low back

means, Further analysis on the scores revealed

pain management at the beginning of the program.

that

these

changes

are

statistically

highly

significant in the control group (t=9.79, p=0.00) RESULTS The outcome of the data was analyzed, using bar-graphical

representation,

mean,

standard

deviation of the pre test and post test values of the two groups individually. Comparison of mean within the group was done and the difference of mean, standard deviation between the group is also done. Calculation was done according to M.S excel soft ware. The mean improvements between the two

Graph No 1: Comparison of disability ((Rolland

groups of low back pain patients were tested for

Morris) within control group.

significance using student t- test. The calculated tvalues for the RMDQ showed a significant

Table No 2: Comparison of disability ((Rolland

variation at p=0.00. It showed that there is fulfilled

Morris) within Experimental group.

improvement in post test RMDQ values when compared to pretest RMDQ values in both the groups., but the mean improvement in the group II that received core strengthening is higher when compared to the group I that received conventional exercise

program.

The

mean

improvements

Scientific Research Journal of India â&#x2014;? Volume: 2, Issue: 3, Year: 2013

The disability in the experimental group has decreased post intervention, as in shown by their means, Further analysis on the scores revealed that

these

changes

are

statistically

highly

significant in the control group (t=6.79, p=0.00)

Graph No 3: Experimental Vs control groupDisability (post pre difference)

Interpretation: The table-1and 2 showed that there is highly significance difference between pre and post test Graph No 2: Comparison of disability within

values of VAS within the groups. The calculated t-

experimental group.

values for the RMDQ showed a significant variation at p=0.00. It showed that there is fulfilled

Table No 3: Experimental Vs control group-

improvement in post test RMDQ values when

Disability (post pre difference)

compared to pretest RMDQ values in both the groups

The table-3 showed that there is highly significance difference between pre and post test values of RMDQ between the two groups.The calculated p value showed a significance of difference in improvement at p=0.011, which The disability in the experimental & control

indicates that experimental group has higher gains

group has decreased post intervention, as in shown

in improvement in RMDQ scale than control

by their means, though the change in the

group.

experimental group was much higher than in the DISCUSSION

control group. Further analysis on the scores

Our

revealed that these changes are statistically

findings

suggest

that

stabilization

exercises reduce subjectâ&#x20AC;&#x2122;s pain more effectively

significant. (t=2.73, p=0.011)

immediately after the end of treatment protocol over general exercise protocol with statistical significant. The results of this study support the initial hypothesis that specific exercise training of the "stability" muscles of the trunk is effective in 13

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chronically

demonstrable benefits, based on previous studies

symptomatic low back pain. Analysis of the pain

of similar or less exercise duration5,17,15,18. Increase

revealed that there is a difference in improvements

in doses of exercise, increase in benefit of

between both the groups. This treatment approach

exercise15. However, the stabilizing function of

was more effective than other conservative

trunk musculature is especially important around

treatment approaches which mainly involved

the neutral posture, where the spine exhibits the

conventional exercise programs. This is in support

least stiffness. Increased neutral zone, a region of

of Punjabiâ&#x20AC;&#x2122;s hypothesis that the stability of the

low stiffness around the neutral spine had been

lumbar spine is dependent not solely on the basic

suggested first by Punjabi19. Richardson suggested

morphology of the spine, but also the correct

that

functioning

system.

exercise for the local deep muscle TrA and LM is

Therefore, if the basic morphology of the lumbar

most beneficial for re-educating the stabilizing

spine is compromised, as in the case with

muscle and can incoporated with dynamic

symptomatic CLBP, the neuromuscular system

functional exercise. In addition, both disuse and

may be trained to compensate, to provide dynamic

reflex inhibition are likely to affect the slow twitch

stability to the spine during the demands of daily

or tonic holding contraction at a low level would

living.Consistent with these findings, McGill

be most effective in retraining the stability

reported that lumbar stability is maintained in vivo

function of these muscle20. The other advantages

by increasing the activity (stiffness) of the lumbar

of core stability strengthening program is that, they

segmental muscles, and highlighted the importance

apart from improving core strength and stability

of motor control to coordinate muscle recruitment

also

between large trunk muscles and small intrinsic

movement, heightened body awareness, balance

muscles during functional activities, to ensure

and

stability is maintained.

significant in early phase of treatment than the

reducing

pain

patients

the

with

neuromuscular

The trunk muscle stabilization exercise group

the

simultaneous

improved

isometric

flexibility,

coordination.

Hence,

posture,

contraction

ease

showed

later phase. In non specific low back pain patients

exercised the TrA and LM muscle . In individual

the neutral zone muscles gets more affected than

with low back pain, the TrA has decreased

the

anticipatory capacity, meaning that it has reduced

rehabilitation of these muscles produced good

segmental protective function . Rodacki et al,

other

muscles

back.

Hence,

early

results within short time.

suggested that abdominal exercises are associated with low back pain improvement, since during abdominal

contraction

intervertebral

disks

the was

pressure decreased

CONCLUSION

on the as

Both the exercise groups showed statistical

significance but stabilization exercise exercise

consequence of the increased intra abdominal

group showed more significant over general

pressure. However, no improvement on TrA

exercise group in reducing disability in nonspecific

capacity were observed . From methodological

low back pain. Specific stabilization exercise

point of view the frequency and duration of the

improves TrA and LM muscle activation capacity.

study were deemed appropriate to produce

So specific stabilization exercise was superior in

Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013

reducing disability than general exercise group.

Biopsychosocial factors were not observed in this

Limitation of the study were no intermediate and

long-term

study.

examination.

REFERENCES

A randomized clinical trial of three active therapies for chronic low back pains, Spine, 24(23), 2435-48 (1999)

Luciana G. Macedo, Christopher G. Maher, Jane Latimer and James H. McAuley, Motor Control Exercise for Persistent, Nonspecific Low Back pain: A Systematic Review, Physical Therapy, 89, 9-25 (2009)

Franca F.R., Burke T.N., Hanada E.S. and Marques AP: Segmental Stabilization and muscular Strengthening in chronic low back pain – a comparative study, Clinics, 65(10), 10131017(2010)

Stuart M McGill, Low Back Exercises, Evidence for Improving Exercise Regimens, Physical Therapy, volume 78, 754-764 (1998)

Hansen F.R. and Bendix T., et al: Intensive, dynamic backmuscle exercises, conventional physiotherapy, or placebocontrol treatment of low-back pain. A randomized, observer-blind trial, Spine, 18, 98-108 (1993)

Rich S.V. and Norvell N.K., et al: Lumbar strengthening in chronic low back pain patients. Physiologic and psychological benefits. Spine , 18(2), 232-8 (1993)

O’Sullivan P.B., Phyty G.D., Twomey L.T. and Allison G.T., Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis, Spine 22(24), 2959-67 (1997)

Hides J.A., Richardson C.A. and Jull G.A., Multifidus muscle recovery is not automatic after resolution of acute, first-episode low back pain, Spine, 21(23), 2763-9 (1996)

Danneels L.A., Cambier D.C., Vanderstraeten G.C., Witvrouw E.E. and Bourgois J., Effect of three different training modalities on the cross-sectional area of the lumbar multifidus muscle in patients with chronic low back pain, Br J Sport, 35, 186-191 (2001)

10.

George A. Kounmanatakis, Paul J. Watson and Trunk Muscle Stabilization Training Plus General Exercise Versus General Exercise Only: Randomized Controlled Trial of Patients With Recurrent Low Back Pain, Apta Physical Therapy, 85, 209-225 (2005)

11.

O’Sullivan P.B., Lumbar segmental instability, clinical presentation and specific stabilizing exercise management manual therapy, 5(2),112 (2000)

12.

Fairbank J.C.T. and Pynsent P.B., Oswestry Disability Questionnaire, Spine, 25(22), 2940-2953 (2000)

13.

Bayar Kilichan, Bayar Banu, Yakut Edibe, Yakut Yuvuz, Reliability and construct validity of the Oswestry Low Back Pain Disability Questionnaire in the elderly with low back pain, Spine 26(24), 2738-2743 (2001) 15

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Segmental stabilization and muscular strengthening in chronic low back pain a comparative study 65(10), 1013– 1017 (2010)

15.

Lindstrom I., Ohlud C. et al, Mobility, strength and fitness after a graded activity program for patients with subacute low back pain, A randomized prospective clinical study with a behavioural therapy approach, spine , 17(6), 641-52 (1976)

16.

Rodacki CLN et al; Spinal unloading after abdominal exercise, Cli Biomech, 23, 8-14 (2008)

17.

Randomised controlled trial of exercise for low back pain: clinical outcomes, costs, and , 319(7205), 279– 283 (1999)

18.

Moffett J.K. and Togerson et al, Randomised controlled trial of exercise for low back pain, clinical outcomes, costs, and preferences, BMJ, 7205, 279-83 (1999)

19.

Panjabi M.M., The stabilizing system of the spine.Part l.Function, Dysfunction, adaptation, and enhancement, J Spinal Disord, 5(4), 385- 9 (1992)

20.

C.A. Richardson and G.A. Jull, Muscle Control- pain control. What exercises would you prescribe – Manual Therapy, 1-16 (1995)

21.

Ariponnammal S., A Novel Method of Using Refractive Index as a Tool for Finding the Adultration of Oils, Res.J.Recent Sci., 1(7), 77-79 (2012)

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Ipatova V.M., Convergence of Numerical Solutions of the Data Assimilation Problem for the Atmospheric GeneralCirculationModel, I. Res.J.Recent Sci., 1(6), 16- 21(2012) 23. Yousef Zandi and Vefa Akpinar M., An Experimental Study on Separately Ground and together Grinding Portland Slag Cements Strength Properties, Res.J.Recent Sci., 1(4), 27- 40(2012)

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Behmaneshfar Ali, Shahbazi S. and Vaezi S., Analysis of the Sampling in Quality Control Charts in non uniform Process by using a New Statistical Algorithm Res.J.Recent Sci., 1(8), 36-41 (2012)

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Nasiripour A.A., Masoudi-asl I. and Hesami F., The Relationship between Nurses Organizational Participation and Patient Safety Culture in Jahrom Motahari Hospital, Iran Res.J.Recent Sci., 1(8), 73 76 (2012)

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Dysmenorrhea Tofighi Niaki M., Zafari M. and Aghamohammady A., Comparison of the effect of Vitamin B1 and Acupuncture on Treatment of Primary ISCA J. Biological Sci., 1(1), 62-66 (2012)

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Balamuralitharan S. and Rajasekaran S., Stability of the Six Equilibrium States between CN and G-CSF with Infectives Growth Rate Progression: A FFT Study, ISCA J. Biological Sci., 1(2), 55-60 (2012)

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Bhatt T.K., Phylogenetic Studies on tRNA Dependent Amidotransferase from Plasmodium Falciparum, ISCA J. Biological Sci., 1(3), 20-24 (2012)

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Lakhani Leena, Khatri Amrita and Choudhary Preeti, Effect of Dimethoate on Testicular Histomorphology of the Earthworm Eudichogaster Kinneari (Stephenson) I. Res. J. Biological Sci., 1(4), 77-80 (2012)

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Scientific Research Journal of India â&#x2014;? Volume: 2, Issue: 3, Year: 2013

J. Biological Sci., 1(5), 53-56 (2012)

CORRESPONDENCE

*PhD Research Scholar , Singhania University, Pacheri Bari, RajasthanIndia **Consultant, Sir Ganga Ram Hospital, New Delhi, India ***Asst. Professor, PDM Group Of Institutions, Bahadurgarh, Haryana, India

STUDY OF RESPIRATORY CAPACITY AND CORE MUSCLE STRENGTH IN INDIAN CLASSICAL SINGERS Shweta S. Devare Phadke*, Sukhada Prabhu**, Sujata Yardi***

ABSTRACT Classical singers are elite athletes. Their art requires total mind & body integration. Body alignment and breathing has an effect on phonation. Proper breathing technique leads to better control over breath and quality of tone. Core muscles supports the work of lungs and larynx to produce better tone production and ability to sing extended phrases and sustain notes for longer.1 OBJECTIVE: To compare core muscle strength and respiratory parameters like peak expiratory flow rate and breathe holding time between Indian classical singers and age matched non singers. METHODOLOGY: Group 1 Indian classical singers between age group of 15 to 30 years, practicing minimum since 1 year. Group 2 Normal healthy adults between age group of 15 to 30 years who are not engaged in any type of singing and fitness activity. After explaining about the aims and objectives of the study , consent taken. Height, weight, core muscle strength assessment by Richardson and Joule's grading, breath holding time and peak expiratory flow rate with mini Wright's peak flow meter measured. The data was analyzed using GraphPadInstat Version3.10, 32 for Windows. RESULT: The core muscle strength and Breath holding time of classical singers is significantly more than age matched normals. There is mean difference in PEFR of singers and age matched normals which is statistically non significant. The study reveals that singers have good core strength and breath holding time. For quality singing training in breathing capacity and core muscle strength will help. KEYWORDS: core muscle strength, indian classical singer, respiratory capacity.

Type of study – Cross Sectional

INTRODUCTION Singing requires exceptional co-ordination,

Study

setting

–

Community

Indian

endurance and fine motor control. Body alignment

classical singer

impacts vocal techniques. Breating capacity have

Inclusion criteria – Indian classical singers

effect on specialised phonation like singing. 3 The

between age group of 15 to 30 years,

physiological

practicing minimum since 1 year.

effects

proper

breathing

techniques are increased lung capacity, increase in

Normal healthy adults between age group

lung volume, improved all over stamina or

of 15 to 30 years who are not engaged in

endurance of respiratory muscles, and better

any type of singing activity.

Exclusion criteria – Indian classical singers

According to Pilates, core strength and

with any lung or cardiac pathology (HTN,

oxygenation of entire body.

stability is of tremendous benefit for breathing.

pregnant women,

The core muscle encompasses all muscles that co-

delivery ).

ordinate the joints of lower spine, pelvis, hip and

Singers engaged in any other physical exercise

stabilize lower torso. Most of these muscles also

or wind instruments.

assist in respiration. The core muscles help singers

Singers less than 1 yr of training and singers

to enhance endurance of respiratory muscles and

who are not undergoing appropriate training.

in turn increase the breathing capacity.3 If muscles

Normal age matched adults involved in any

that support the breathing mechanism are well toned, singing will be energy efficient.2

within 6 months post

type of physical fitness activity.

Core MATERIAL USED

muscles works by contracting the abdominal muscles, creating higher pressure in abdomen ,

Stabilizer’s pressure biofeedback unit

allowing diaphragms relaxation, upward rise to be more carefully controlled. Core muscle gives singer a means of controlling their sound or phonation.1 Breath holding time is a rough index of cardiopulmonary reserve measured by length of time that a subject can voluntarily stop breathing after a deep inspiration. Learning to catch and time

Mini Wright’s peak expiratory flow meter

the breath for each song is critical for a quality performance.5 Thus, we hypothesised, the core muscle strength and respiratory capacity measured by peak expiratory flow rate and breath holding time of Indian classical singers are higher than age matched healthy adults.

Weighing scale Measuring tape and stop watch

METHODOLOGY

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plinth.

Procedure

2A- Unilateral heel slide with other leg off the 1.Core

muscle

strength

was

measured

plinth in hip knee flexion.

Stabilizer’s pressure biofeedback unit, with help of

2B- Unilateral heel slide with leg 5cm off the

Richardson and Joule’s core muscle grading

plinth and leg off the plinth in hip knee flexion.

method. This grading method was used as it is

2. Peak expiratory flow rate was measured by Mini

reliable and valid method of testing core muscle

Wright’s peak expiratory flow meter, a small

strength.18 The subject was instructed to be in

handheld device. Subject was in standing position

supine position with both lower limbs hip and knee

without any support. They were instructed to take

flexed. Drawing in maneuver i.e transverse

a deep inspiration through nose with device held in

abdominis muscle activation was taught to the

mouth, and to blow out or expire forcefully

subject. The inflatable bag was placed in lumbar

through mouth. 3 readings were taken, out of

lordosis and pressure was raised till 40mm of Hg.

which the best value was considered.17

Subjects were instructed to take their umbilicus

3. Breath holding time was measured with the help

upward and inward and maintaining this they were

of stop watch. Subjects were in sitting position.

graded as per following grades19-

They were instructed to take a deep inspiration

1A- Unilateral heel slide, with other leg in hip

through nose and to hold their breath as long as

knee flexion resting on plinth.

possible. The normal duration was 30 seconds or

1B- Unilateral heel slide with leg 5cms off the

longer, diminished cardiac or pulmonary reserve

plinth and other leg in hip knee flexion resting on

was indicated by duration of 20 seconds or less.5

RESULT Table 1: Comparison of core muscle strength by richardson and joule’s grading Singers

Normals

Mean

2.9

1.433

Standard diviation

1.248

0.5683

'P' value

<0.0001

Table 2: Comparision of breath holding time Singers

Normals

Mean

48.7

37.9

Standard diviation

9.963

8.588

'P' value

>0.01

Scientific Research Journal of India â&#x2014;? Volume: 2, Issue: 3, Year: 2013

Table 3: Comparision of peak expiratory flow rate Singers

Normals

Mean

371.33

359

Standard diviation

42.160

55.108

'P' value

>0.10

DISCUSSION In our study, total 60 subjects participated, 30

vibrate. If a singer tends to push, a stronger core

in each group. Subjects were explained about the

will make it possible to push a little harder.3 Core

study and a prior consent was taken. The age,

strength and stability is of tremendous benefit for

height (in cms), weight (in kgs), no.of training

breath

years of the study subjects were noted. Subjects

strengthening exercises that strengthen the core

were assessed on parameters like core muscle

muscle along with abdominal muscle, back

strength, breath holding time, peak expiratory flow

muscle, muscle around pelvis are recommended

rate (PEFR) in random order.

for singers as daily exercise program along with

co-ordination

during

singing.

Core

The data revealed that maximum no. of

their singing practice to sustain notes for longer

singers are trained for 5-6 years. In order to

duration. This will also minimize work related

maintain homogeneous distribution these subjects

musculoskeletal disorders. Breath holding time of

were matched based on age, height (singers- 160.4

classical singers is significantly higher than age

cms, normals- 160.04 cms), and weight (singers-

matched normals. Singers require a higher rate of

61.66 kgs, normals- 60.86 kgs). The maximum no.

breath management capabilities as they need to

of study subjects assessed were females (singers-

extend the normal breath cycle by maintaining

86.6% and normals- 90%).

inspiratory position for as long as possible.3 Breathing strategies rely on ability to inhale a

The statistical analysis shows that core was

substantial quantity of air and release it steadily.

significantly high (P value-0.0009 ). This goes

This physiological mechanism of breathing is

along with our hypothesis that singers need to

relevant to singers as it provides energy to tone

build strength and flexibility throughout the torso.

and ability to sustain longer notes. Without

The strong core muscle supports the muscles of

diaphragm and the muscles surrounding that

spine and lower ribs. which help to enhance rib

support its work, air can neither enter nor leave

movement, resulting in improved breath capacity.

from lungs. Without air expulsion the vocal cords

Thus core muscle strength if developed in proper

cannot vibrate and without vibration sound canâ&#x20AC;&#x2122;t

fashion helps to improve breath capacity in

be produced.1 Cardiopulmonary fitness plays

singers.3 A good core encourages singer in

important role in singing. It includes efficient

pushing. Pushing results when vocal cords are

circulation of oxygen throughout the body and

squeezed together with such force that only

ability to make good use of it.3 Efficient oxygen

excessive breath pressure will allow them to

consumption benefits singing techniques by

muscle

strength

classical

singers

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allowing singer to sustain longer phrases. Building

and steady expiration is recommended for singers

strong core strength leads to less work of

to sustain longer notes. Thus cardiopulmonary fitness and core muscle

breathing.3

strengthening plays important role in improving

There are 2 schools of teaching about breath

quality of singing. The study reveals that singers

management 1 •

require good core strengthening and breath holding Supporting the breath by compressing abdomen

during

phonation

(i.e.

time for quality singing. Hence clinically singer

fitness programme must include core muscle

exhalation) •

strength training and breathing exercises.

Relaxing abdominal muscle as much as possible during inhalation and phonation,

Acknowledgements

allowing diaphragm to work on inhalation

We are heartily thankful to Yashsree Sangeet

and riding its relaxation on outgoing

Vidyalaya,Kalva and the staff of Dept. Of

breath (i.e. during phonation)

Physiotherapy, Pad.Dr.D.Y.Patil University, who supported us from the preliminary stages of the

In our study as breath holding time was higher

project.

in singers so we would like to emphasis that inspiratory training would help singers to sustain

Conflict of Interest

notes for longer.

We, Phadke S,Prabhu S, Yardi S state that

From the study it is evident that there is no

there is no conflict of interests with other people or

much significant difference in PEFR of singers as

organizations about our work.

compared to age matched normals. PEFR is person’s maximum speed of expiration. PEFR

Source of funding

measures airflow through bronchi and thus degree

Study was self funded.

of obstruction in the airways.6 The PEFR values of singer are nearly same as those of normals may

Ethical Clearance

be because singers have to concentrate more on

Study has cleared by ethical committee of

inspiratory capacity and breath holding. Relaxed

Padmashree

Dr.

D.Y.

Patil

University.

REFERENCES 1. Sing wise effective and proper breathing- An information based resource for singers. Karyn O’ Connor, 2011, page no1. 2. Sing wise effective and proper breathing- An information based resource for singers. Karyn O’ Connor, 2011, page no2. 3. Sports specific training for vocal athlete- how exercise can support your vocal techniques. Claudia Freidlander, CPT, part 1. 4. Exercise to improve your core strength- by Mayoclinic staff. Mayo foundation for medical education and research.

Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013

5. Breath holding after breathing of oxygen. F.J. klocke and H. Rahn. Journal of applied physiology, American physiological society. 6. Peak expiratory flow rate. The Indian journal of pediatrics. Nov-Dec 1994, volume 61, issue 6, page no. 701 . 7. An investigation of abdominal muscle recruitment for sustained phonation in 25 healthy singers. Ian MacDonald, John S. Rubin, Ed Blake et all. Journal of voice, volume 26, issue 6, Nov 2012, page nos. 815e.9-815e.16 8. Reduced pulmonary function in wind instrument players.

Omer Deniz, Sema Savci, Ergun

Tozkoparan et al. Archives of Medical Research, volume 37, issue 4, May 2006, page nos. 506-517. 9. Respiratory muscle training for singers by using respiratory muscle training device.Do Hyun Nam, Jan Yol Lim, Chul Min Ahn et al.Yonsei Medical Journal, volume 45, issue 5, 2004, page nos.810 817 10. Study on breathing method for improving singing skills. Tae-seon-Cho Book- Green and smart technology with sensor application, volume-338, 2012, page nos.372-377 11. Principles and practice of cardiopulmonary physical therapy (3rd edition) – Donna Frownfelter, Elizabeth Dean. 12. Reliability of test measuring transverses abdominis muscle recruitment with a pressure biofeedback unit. Katharnia von Garnier et al. Physiotherapy, volume 95, issue 1, March 2009, page nos. 8-14 13. Inefficient muscular stabilization of lumbar spine associated with low back pain; a motor control evaluation of transverses abdominis muscle. Hodges PW, Richardson CA, 1996, issue 35, page nos. 783-805. 14. Tidy’s physiotherapy –by Staurt Porter. 14th edition.

CORRESPONDING AUTHOR: *Asst. Professore, Dept. Of Physiotherapy, Pad Dr. D.Y. Patil University, 6th floor, Pad Dr. D.Y. Patil Medical College Bldg., Sector 5, Nerul, Navi Mumbai. **Intern, Dept. Of Physiotherapy, Pad Dr. D.Y. Patil University, 6th floor, Pad Dr. D.Y. Patil Medical College Bldg., Sector 5, Nerul, Navi Mumbai. ***Professore & Director, Dept. Of Physiotherapy, Pad Dr. D.Y. Patil University, 6th floor, Pad Dr. D.Y. Patil Medical College Bldg., Sector 5, Nerul, Navi Mumbai.

AEROBIC CAPACITY, BODY MASS INDEX AND FAT FOLD MEASUREMENTS OF HEALTHY ATHLETES IN DEHRADUN – A CROSS SECTIONAL STUDY Sharma Chetan, MPT (Sports), Dr. Dar Shahid Mohd., MPT (Orthopedic and Sports)

ABSTRACT PURPOSE: The Aim of Present study was done to assess the Percent Body fat, Body Mass Index and VO2 Max for the athletes of Dehradun. The study would create a data for athletes in Dehradun involved in various sporting activities which would catagorised the subject having recommended parameters of fitness. METHODOLOGY: A survey Study with measurement of Aerobic capacity, Body Mass Index and Percent Body Fat was done. Total of 96 subjects was included based on the inclusion and exclusion criteria. Convenience Sampling was used for the selection of participants. Descriptive Statistics has been used for the analysis of the data. RESULTS: A sample of 96 Athletes with Mean Age (15.634±2.54 years) had a mean Percent Body Fat 10.537±3.51 percent, mean Body Mass Index 18.654±1.64 kg/m2 and mean VO2 Max is 41.943±6.777 ml/kg/min. CONCLUSION: There was no significant correlation found between VO2 max, Body Mass Index and Percent Body Fat. KEY WORDS: Aerobic capacity, Body Mass Index, VO2 Max, Percent Body Fat, 20 m Shuttle Run Test.

(VO2max) itself is difficult, exhausting and often

INTRODUCTION Direct measurement of maximum oxygen

hazardous to perform regardless the type of

uptake (VO2max) is recognized as the best single

ergometer used. Since the direct testing procedure

index of aerobic fitness, but the test of the direct

is rather complicated on larger populations, several

measurement

indirect running and walking field tests have been

cardiorespiratory

endurance

Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013

developed. Scientists often calculate VO2max with

environment. The accuracy of predicting percent

indirect protocols. It has been stated that equations

fat from skinfolds is approximately ± 3.5%

for predicting VO2max indirectly using field tests

assuming

are very sensitive to populations tested on.

equations have been used.1

that

appropriate

techniques

and

Therefore, before applying any indirect protocol for prediction of VO2max, the validity of the test

METHODOLOGY

should be established in a particular population.4 Body mass index (BMI) is used as a

Design

surrogate for percent fat in classifying obesity.

This is a Cross sectional study. All the

However, there is no established criterion for

subjects were recruited from the various sports

percent fat and health risk, and few studies have

center from Dehradun.

examined the validity of Body Mass Index as a measure of Percent fat. Body Mass Index is used

Sampling

to classify athletes and young adults as obese.

Total of 96 subjects were chosen as per the

Consequently, it is critical to understand the

inclusion and exclusion criteria, and informed

accuracy of Body Mass Index in this populations.1

consent was obtained from all the subjects after the

Body mass index is currently the most frequently

procedure was explained to them.

used and widely accepted method to classify medical risk according to weight status. Body

Procedure:

Mass Index is a useful measure of adiposity in young and middle-aged athletes.

20 Meter shuttle run test: The 20 Meter

Shuttle Run Test was administered in a sports field from

using the original protocol (Leger and Lambert,

skinfold measurements correlates well (r = 0.70–

1986) but utilizing a different scoring system

0.90) with body composition determined by hydro

developed by the Human Performance Laboratory

densitometry. The principle behind this technique

at The Queen's University of Belfast.7 The 20

is that the amount of subcutaneous fat is

Meter Shuttle Run test involves running between

proportional to the total amount of body fat. It is

two lines set 20 meters apart at a pace dictated by

assumed that close to one third of the total fat is

a cassette recording emitting tones at appropriate

located subcutaneously. The exact proportion of

intervals. The test score achieved by the subject is

subcutaneous-to-total fat varies with sex, age, and

the number of 20 meter laps completed before the

ethnicity. Therefore, regression equations used to

subject either withdraws voluntarily from the test.

convert sum of skinfolds to percent body fat must

Scoring by aps differs from the "paliers", 6 used in

consider these variables for greatest accuracy. To

the original version of the test. The test is made up

improve the accuracy of the measurement, it is

of 23 levels where each level lasts approximately

recommended that one train with a skilled

one minute. Each level comprises of a series of

technician, use video media that demonstrate

20m shuttle runs where the starting speed is 8.5

proper technique, participate in workshops, and

km/hr and increases by 0.5km/hr at each level. On

increase experience in a supervised practical

the tape/Compact Disc a single beep indicates the

Body

composition

determined

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end of a shuttle and 3 beeps indicates the start of

Percent body fat, Body mass index and VO2 max

the next level.

in total no of subjects.

Body Mass Index: The Body Mass Index is used to assess weight relative to height and is

Table 2: Correlation between Body Mass Index

calculated by dividing body weight in kilograms

and VO2 Max as well as Percent Body fat and Vo2

-2 1

max in total no. of Subjects.

by height in meters squared (kg.m ).

Skinfold Measurement: Body composition determined from skin fold measurements. Seven Site Formula for Men (chest, mid-axillary, triceps, subscapular, abdomen, Supra iliac, thigh). Body density = 1.112 - 0.00043499 (sum of seven skinfolds)

0.00000055

skinfolds) - 0.00028826 (age) ~3.5% fat).

(sum

seven

[SEE 0.008 or No significant variation was observed (p >

0.05) between the values of Body Mass Index and VO2max as well as Percent Body Fat and Vo2

RESULTS:

max. Correlation was done for comparison

Means and standard deviations of athletes

between Percent Body fat and VO2 Max was found

in Dehradun, predicted VO2max by the 20-m

that r = 0.058 which is not significant (p = 0.576)

multi stage shuttle run test, Age, Body mass index

and another Correlation has been done between

and Percent body fat were presented in the Table

Body Mass Index and VO2 max was found to be r

= -0.037 which is also not significant (p = 0.721), thus finding not significant between the respective

Table 1:- Mean and Standard deviation for Age,

variables.

Percent Body fat, Body Mass Index and Vo2 max in total no. of subjects.

DISCUSSION The Aim of Present study was done to assess the Percent Body fat, Body Mass Index and VO2 Max for the athletes of Dehradun. The athletes were recruited mainly from different types of sports those who participate in sporting activities in different colleges and academies. A sample

Athletes

with

Mean

Age

(15.634±2.54 years) had a mean Percent Body Fat 10.537±3.51 percent, mean Body Mass Index 18.654±1.64 kg/m2 and mean VO2 Max is 41.943±6.777 ml/kg/min. In this study Pearson Correlation was done for comparison between Figure 1: Mean with Standard deviation of Age,

Percent Body fat and VO2 Max was found that r = 26

Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013

0.058 which is not significant (p > .05) and

study Wan Nudri WD et al. from Division of

another Correlation has been done between Body

Human Nutrition, Institute for Medical Research,

Mass Index and VO2 max was found to be r = -

Kuala Lumpur, has found mean Body Mass Index

0.037 which is also not significant (p > .05), thus

of athletes with age of (23.9±4.2 years) is

finding not significant between the respective

(22.9±3.5 kg/m2)10 the probable reason for the

variables.

difference between Body Mass Index of both study

In the present study it has been found that

is the age. However it was clear that the athletes

Mean Vo2 max for 96 active athletes of age group

who had reduced level of Body Mass Index were

of 10-30 years in five different kinds of sports is

due to lean muscle mass.28 From 5 to 16 years of

(41.943 ml/kg/min), while in a similar study was

age, boy’s relative muscle mass increases from

done by S. K. VERMA et al. Department of

about 42–54% of body mass.2

Human Biology, Punjabi University, Patiala who

A paper review done by American Dietetic

found that the mean V02 max in 96 active athletes

Association, Dietitians of Canada, and the

age group of 17-25 years was 48.4 ± 5.1 ml/kg/min

American College of Sports Medicine stated that

with a highest value of 56.4 ml/kg/min and lowest

the male athletes with the lowest estimates of body

value of 44.2 ml/kg/min. Which is slightly higher

fat (less than 6%) include middle-distance and

as compared to V02 max values recorded in the

long-distance runners and bodybuilders, whereas

present study, this probably can be due to the

male

greater body surface area of athletes in S.K.

sprinters,

Verma’s study where the age group of the subjects

average between 6% to 15% body fat. Male

basketball

players,

jumpers,

cyclists,

triathletes,

and

gymnasts, wrestlers

was greater (17-25 years). Where as in the present

athletes involved in power sports such as football,

study the maximum sample obtained was in the

rugby, and ice and field hockey have slightly more

range of 10-20 years because of non-availability of

variable body fat levels 6% to 19%.8 The present

the athletes in the elder age group. As the age

study is done on population of Dehradun, India.

increases the body surface area increases as is

Although, there may be racial differences between

already proved and the increase in the aerobic

both the populations, it was found that level of

capacity with age is also a well-established fact,4

percent body fat had a similarity.

so our values of less vo2max readings in subjects

In this study a Correlation between percent

of lesser age group than readings of other studies

body fat and Vo2max also was done and study

is quite well understood. Hence forth we

found that the two variables are not significantly

recommend that in future the studies should make

correlated (r=.058, p > .05) . Similarly Body Mass

sure that the sample possess the even distribution

Index and Vo2max also were found to be

of all age groups i.e.… 10-30 years.

correlated non-significantly (r = -.037, p > .05).

As far as Body Mass Index of male

This is in contradiction with other studies done in

athletes in Dehradun is concerned, the present

the past who have found a positive correlation

study found that the mean of Body Mass Index

between BMI and Percent body fat with VO2

was 18.654±1.64 kg/m . Percent body fat is

max.10 The reason for non-significant correlation

10.537±3.51 percentage. In support of present

in present study could be due to the non-

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homogeneity of the sample of our study, i.e….in

athletes,

found

out

Mean

VO2

max

was

present study athletes from all the games with

41.943±6.777 ml/kg/min, mean Body mass index

different Body Composition were included, which

was 18.654±1.64 kg/m2 and mean Percent body fat

could have given a unexpected result.

was 10.537±3.51 percent. There was no significant correlation was found between Variables which

CONCLUSION:

could have been because of non-homogenous

Study is done to access VO2 max, Body mass

group.

index and Percent body fat in a sample of 96 REFERENCES: 1. Armstrong L, phd, FACSM, Balady G. J., MD, Berry M.J., phd, FACSM. ACSM's guidelines for exercise testing and prescription. 7thed. New York. Lippincott Williams & Wilkins 2006; p. 64. 2. Armstrong N, Grant R Tomkinson GR, Ekelund Ulf. Aerobic fitness and its relationship to sport, exercise training and habitual physical activity during youth. Br J Sports Med. 2011; 45:849–858. doi:10.1136/850 bjsports-2011-090200. 3. Eliakim A, Burke G S, Cooper D M. Fitness, fatness, and the effect of training assessed by magnetic resonance imaging and skinfold-thickness measurements in healthy adolescent females. Am J Cliii Nutr. 1997; 66: 223-31. 4. Leger L, Gadoury C et al. Validity of the 20 m shuttle run test with 1 min stages to predict VO2max in adults. Can J Sport Sci. 1989; 14(1):21-6. 5. Leitzmann MF, Moore sc, Koster a, Harris tb, Park y, et al. (2011) Waist Circumference as Compared with Body-Mass Index in Predicting Mortality from Specific Causes. Plos One. 2011 April; 6(4): e18582. Doi:10.1371. 6. Mechelen W.V, Hlobil H, Kemper H.C.G. Validation of two running tests as estimates of maximal aerobic power in children. European journal of applied physiology and occupational physiology. 1986; 55 (5), 503-506, DOI: 10.1007/BF00421645. 7. Paliczka V.J, Nichols A.K, boreham C.A.G. A multi-stage shuttle runs as a predictor of running performance and maximal oxygen uptake in adults. Brit.j.sports med. 1987; 21(4): pp. 163-165. 8. The American College of Sports Medicine, The American Dietetic Association, The Dietitians of Canada. Nutrition and Athletic Performance. Medicine & science in sports & exercise. 2000; 01959131/00/3212-2130/0. 9. Verma S. K, L. S. Sidhu, Kansal D. K. Aerobic work capacity in young sedentary men and Active athletes in India. Brit. J. Sports Med. 1979; 13: 98-102. 10. Wan Nudri WD, Ismail MN and Zawiak H. Anthropometric measurements and body composition of selected national athletes. Mal J Nutr. 1996; 2: 138-147.

CORRESPONDING AUTHOR:

Scientific Research Journal of India â&#x2014;? Volume: 2, Issue: 3, Year: 2013

*M.P.T. (Neurology)., F.N.R., P.G.C.D.E. Health Care Consultant, Bharathidasan Matric Hr Sec School, Kanchipuram, Tamilnadu, India. & Consultant Physical Therapist, Star Health Care Center, Kanchipuram, Tamilnadu, India. **Bachelors in Physiotherapy (India), PG Dip Sci - Exercise Rehabilitation (Clinical Exercise Physiology), University of Auckland, New Zealand.

EFFECTS OF BIMANUAL FUNCTIONAL PRACTICE TRAINING ON FUNCTIONAL PERFORMANCE OF UPPER EXTREMITY IN CHRONIC STROKE Dr Jasmine Anandabai*, Dr Manish Gupta**

ABSTRACT OBJECTIVE: To study the effects of bimanual functional practice training on functional performance of upper extremity in chronic stroke. DESIGN: Pre-test and Post test design. SETTING: Inpatient and rehabilitation hospital. PARTICIPANTS: Patients were randomized to receive bimanual functional practice (n=15) at 3-4 months post-stroke onset. INTERVENTION: Supervised bimanual training for 50 minutes on 5 days week over 2 weeks using a standardized program. MAIN OUTCOME MEASURES: Upper extremity outcomes were assessed by Graded Wolf-Motor Function Test (GWMFT) and Fugl-Meyer scale (F.M.S). RESULTS: Significant differences were found within the group in mean performance time -p=0.002 and there were significant difference found in functional ability scale (GWMFT-FAS p=0.00, similarly, there were significant changes in Fugl-Meyer score p=0.00. CONCLUSION: This study suggests that 2 sessions of 25 minutes a day of bilateral training of functionally related tasks is effective for upper limb functional recovery in chronic stroke patients, regardless of the initial severity of the impairment. Further more, for recovery of functional motor performance, bimanual practices appears more beneficial. Several other studies have found benefits of bimanual training: therefore, this approach can be accepted as an upper limb intervention in stroke on the basis of finding of this study.

KEYWORDS: Stroke, Functional Performance, Bimanual Functional Practice Training

origin); this constitutes 30-40% of all ischemic

INTRODUCTION

strokes. Stroke is an acute onset of neurological

Ischemic: Ischemic stroke occurs due to a loss

dysfunction due to an abnormality in cerebral

of blood supply to part of the brain, initiating the

circulation with resultant signs and symptoms that

ischemic cascade. Brain tissue ceases to function if

corresponds to involvement of focal areas of the

deprived of oxygen for more than 60 to 90 seconds

brain1. This can be due to ischemia (lack of blood

and after a few hours will suffer irreversible injury

supply) caused by thrombosis or embolism or due

possibly leading to death of the tissue, i.e.,

to a hemorrhage. As a result, the affected area of

infarction.

the brain is unable to function, leading to inability

Hemorrhagic: Hemorrhagic strokes result in

to move one or more limbs on one side of the

tissue injury by causing compression of tissue

body, inability to understand or formulate speech

from an expanding hematoma or hematomas. This

or inability to see one side of the visual field. In

can distort and injure tissue. In addition, the

the past, stroke was referred to as cerebrovascular

pressure may lead to a loss of blood supply to

accident or CVA, but the term "stroke" is now

affected tissue with resulting infarction.

preferred.

Epidemiology: Stroke is a major global health

The traditional definition of stroke, devised

problem. It is the third most common cause of

by the World Health Organization in the 1970s, is

death in world and risk factors for stroke onset are

a "neurological deficit of cerebrovascular cause

high blood pressure, smoking, diabetes, heart

that persists beyond 24 hours or is interrupted by

failure, carotid artery stenosis and hyperlipidemia

death within 24 hours". Strokes can be classified into

two

major

categories:

ischemic

(SBU 1992; Gresham et al. 1995). 3

and

Approximately 85% of all stroke cases are

hemorrhagic. Ischemia is due to interruption of the

ischemic, and most ischemic strokes affect one of

blood supply, while hemorrhage is due to rupture

the cerebral hemispheres by occlusion of the

of a blood vessel or an abnormal vascular

middle cerebral artery (MCA). In the acute stage,

structure. 80% of strokes are due to ischemia; the remainders

are

due

hemorrhage.

mechanisms such as oxygen depletion, necrosis,

Some

brain edema, excitotoxicity and inflammatory

hemorrhages develop inside areas of ischemia ("hemorrhagic transformation").

processes are at play. After the acute stage there is

In an ischemic

a phase of regeneration with neuronal plasticity

stroke, blood supply to part of the brain is

and

decreased, leading to dysfunction of the brain

(partial)

functional

recovery

(Dahlquist

2003).4

tissue in that area. There are four reasons why this

The

might happen: thrombosis (obstruction of a blood

effectiveness

based

neurodevelopment techniques, repetitive unilateral

vessel by a blood clot forming locally), embolism

or bilateral training techniques; sensoriomotor

(idem due to an embolus from elsewhere in the

training or constraint induced movement therapy

body, see below), systemic hypo perfusion

has been evaluated on motor performance of the

(general decrease in blood supply, e.g. in shock)

affected arm of subjects with stroke. The

and venous thrombosis. Stroke without an obvious

Constraint induced movement therapy concept has

explanation is termed "cryptogenic" (of unknown 31

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been derived from basic research with monkeys

function relative to non-affected side (at least

and consists of a family of techniques, i.e.,

100 of wrist extension and at least 100 of

constraining movements of the less affected arm

active extension of each metacarpophalengeal

and intensively training of the more affected arm

joint and interphalengeal joint of all digits.

(Taub et al. 1993; Taub et al. 1999; Morris and Taub 2001).

Bilateral training activities may increase the activity of the affected hemisphere and decrease

No multiple infarctions.

Intact cognitive functions

Patients with right hand dominance with

affected left Hemispheres.

the activity of unaffected hemisphere providing a balancing

effect

between

cortocomotorneuron exitibility. The

practice

hemispheric

Exclusion Criteria:

bilateral

1. Insufficient stamina to participate. symmetrical

2. Other neurological disorders

movements may allow the activation of the intact

3. Previous participation in other pharmalogical

hemisphere to facilitate the activation of the

or Physical intervention

damaged

4. Any severe contractures and deformity in

hemisphere

leading

improve

studies.

movement control of impaired limb promoting

upper Extremity.

neural plasticity. Bimanual practice is getting both

5. Aphasia with inability to follow 2 step

hands to work co-operatively to hold and

commands.

manipulate an object using each hand to perform different actions.

On the first visit a complete neurological

Thus the objective of this study is to establish

assessment was done. Subjects found suitable for

the efficacy of bimanual functional practice on

participants in the study as per the inclusion and

functional performance of upper extremity in

exclusion criteria were requested to sign the

chronic stroke.

consent form. A detailed subjective examination was

METHODOLOGY

taken

regarding

type,

side,

duration,

occurrence of stroke, handedness and motor

A total of 15 subjects (12 males and 3

functions.

females), at O.P.D. of various hospitals, were

All the selected subjects were informed in

included in the study. They were given bimanual

detail about the type and nature of the study and

practice intervention for 5 days a week for 2

asked to sign the informed consent.

weeks. Each treatment session will be of 1 hour.

After taking down the demographic data the measurement of functional performance were

Inclusion Criteria:

assessed by Fugl- Mayer assessment scale and

Graded Wolf Motor Function test.

All Participants suffering from stoke for the

first time. 2.

Onset from 3-9 months

Age group 40-60 yrs.

Most component of movement present in

Participants

were

trained

for

bimanual

activity. Participants were encouraged to do the bimanual practices for 25 minutes with 10 minutes

affected extremity but impairment of 32

Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013

rest periods.

task was practiced for 5 minutes in two sessions.

The total time period of the bimanual practice

Asked the patient to hold the lock with non-

was one hour, which was divided into two training

affected hand and open the lock or move the key in

sessions (25*2=50 min) and one rest period of 10

the lock clockwise and anticlockwise for 5 minutes

minutes.

daily in two sessions.

Participants

were

trained

for

following

bimanual task practices (15). •

RESULTS The results in table 5.4 show that MPT of

Pouring of water from one cup to another

Wolf-motor Function Scale after 2 weeks of

cup with arm held up. •

bilateral training program was significantly less.

Using the telephone (one hand to hold

Similarly FAS score improved significantly after a

receiver and another to dial the number •

Rolling up a towel

•

Unscrewing a jar.

•

Turning the key in lock

Each

participants

2 weeks training program.

Table-1 Group Analysis

were

taught

about

individually and Sitting at the chair comfortably in front of the table.

To ask the patient to hold the one cup with

one hand (non-affected) which was initially filled The results showed that there was significant

with water and asked to hold the cup with other

difference in the bilateral arm training group, both

hand (affected) and both hands held up the table.

pre intervention and again after 2 weeks of

Instruct the patient to pour the water first from

training.

non-affected hand to affected hand and then affected hand to non-affected. This task was

DISCUSSION

performed for 5 minutes daily in two sessions. 2.

The study compared the effects of bilateral

To ask the patients to hold the receiver with

upper limb-task training on upper limb motor

one hand (non-affected) and the numbers with

functions during post stroke rehabilitation. The

another hand (affected) again this task performed

result of this study showed that there was a

alternately hold the receiver with affected hand

significant improvement in functional performance

and dials the numbers with affected hand. 3.

of upper extremity on G.W.M.F.T. and Fugl-

Initially fold the towel lengthwise and asked

Meyer scale in chronic stroke patients after 2

the patient to roll the towel with both hands up to

weeks of bimanual functional practice.

the towel end. 4.

The result of the study showed that there was

Asked the patients to hold the jar with non-

significant difference in bimanual Pre and Post

affected and practiced to open the jar or move the

practice group on GWMFT (Pre MPT: p=0.70 &

cup of the jar to clockwise and anticlockwise. This 33

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Post MPT: p=0.75 and Pre FAS: p=0.32 & Post

processing information from the non-paretic limb,

FAS: p=0.312) and Fugl-Meyer score. (Pre:

while simultaneously attempting to perform new,

p=0.519 and Post: p=0.43)

progressively changing, relatively complex precise motor goals with both arms may have provided a

Participants of bimanual practice group

dual-task challenge greater than in other studies.

showed a decrease in performance time (p=0.002) and increase on functional ability score (p=0.00)

The effectiveness of bilateral movement

and showed highly significant improvement on

training in promoting stroke recovery is also likely

motor functional performance of Fugl-Meyer scale

to depend on the extent of damage sustained to

(p=0.00).The mean time to perform 15 tasks in

direct corticospinal pathways58. While bilateral

GWMFT was (17.13+4.60) which decreased after

movements may also help recruit secondary motor

training

areas in both hemispheres, recovery promoted by

(15.80+5.53) and the functional ability score

these areas will be less than that obtained through

(1.75+0.46)

direct corticospinal projections

weeks

bimanual

improved

practice

after

training

58, 59

. This can be

(2.05+0.57).The result showed that 2 weeks of

explained by the changes in the functional ability

bimanual training improved motor functional

of impaired limb as evidenced by GWMFT scores

performance on Fugl-Meyer scale (42.87+5.25).

and in motor performance by Fugl-Meyer score in

The result showed that 2 weeks of bimanual

the patient group used in the study. Recent

training improves motor functional performance

research has shown that lesion location greatly

on Fugl-Meyer scale (44.53+6.20).

influences the pattern of motor cortex excitability observed 60.

The result of the study suggested that, training involving the practice of actions bilaterally and

Intervention timing may have influenced

simultaneously is effective in promoting recovery

outcomes. The study showed significant effects of

of upper limb motor function in chronic stroke

bilateral training in chronic stroke participants,

patients. Of particular importance was significant

whereas some studies showed no effects of

increase in participants of the bilateral training

bilateral training in patients with acute stroke

group in functional ability of the upper limb,

Stroke appears to alter normal transcallosal

demonstrating a generalization from the training of

inhibition resulting in increased intact hemisphere

a specific movement to general upper limb

excitability during hemiparetic arm movement that

function. Individuals receiving bilateral training

may be inhibitory in nature, thus suppressing

showed improvements in the time to complete the

output

graded wolf motor function test (GWMFT)

Depending on the lesion site and size, these over

movement with the impaired limb .

from

the

damaged

hemisphere

activation appear transient, and more normal

In the study, participants were trained in

contralateral activation pattern resume over time

complex multi joint functionally relevant tasks,

whereas other bilateral training studies have

hemisphere

involved

modulate transcallosal inhibition, balancing stroke

protocols

using

simple

repetitive

or auditory

movements with electric stimulation cueing

35,

Furthermore

visualizing

. Identical motor commands generated in each

and

during

bilateral

interhemspheric

over

movement

activity

may

and

facilitating output from the damage hemisphere as

Scientific Research Journal of India â&#x2014;? Volume: 2, Issue: 3, Year: 2013

well as from normally inhibited ipsilateral pathway

bimanually.Initially, just after stroke, bimanual

movement enhanced activation in the primary

the

undamaged

hemisphere

augment

movement of the paretic arm 50.

motor cortex M1 of the affected hemisphere did

there is a strong neurophysiological evidence

not differ between unimanual paretic hand and bimanual movement 14.

to suggest that when the impaired and non impaired arms are moved symmetrically, crossed

The frequency and duration of the program

facilitatory drive from the intact hemisphere will

may not have been optimal. One may ask whether

be produced increase excitability in homologous

20 25-minutes sessions devoted to the bimanual

motor pathways in the impaired limb

50, 51

task are sufficient to trigger brain reorganization

Additionally, cortical damage from stroke

and to observe a change. This scheduled was based

produces hyperexcitability of the contralesional

on practical reason and although it is similar to

that used in previous study 34, 61,

leading to abnormally high levels of

transcollasal inhibition (TCI) on the legend

The study does not suggest the training

hemisphere, thereby further impairing motor

characteristics, such as the nature of the tasks and

performance of the paretic hand 53. There is recent

strength of inter limb coupling required for effects

evidence of improved affected hand performance

, may influenced outcomes: therefore future work

in chronic stroke patients from reducing the

should examined the optimal timing, dose and

abnormal inhibitory drive to the ipsilesional

training tasks that might optimize the already

hemisphere

54,

Further

more,

balanced

known facilitatory effects of interlimb coupling.

interhemspheric interactions appear necessary for normal voluntary movements

between

CONCLUSION

and the restitution two

This study suggest that 2 sessions of 25

hemispheres has been linked to better recovery

minutes a day of bilateral training of functionally

the

normal

balance

the

. It has been hypothesized that

related tasks is effective for upper limb functional

practicing by lateral symmetrical movements may

recovery in chronic stroke patients, regardless of

facilitate motor output from the ipsilesional

the initial severity of the impairment.

following stroke

hemisphere by normalizing (TCI) influences.

Furthermore, for recovery of functional motor

Interestingly, in the subset of patients assessed

performance, bilateral training appears beneficial.

with wolf motor function test and Fugl-Meyer

Several other studies have found benefits of

scale in the study the bilateral trained patients

bimanual training: therefore, this approach can be

exhibiting the largest increase in functional ability.

accepted as an upper limb intervention in stroke on

In addition, bilateral training may promote

the basis of finding this study.

not

The study does not suggest the training

investigated in the present study such as spared

characteristics, such as the nature of the tasks and

corticopropriospinal pathways 50.

strength of inter limb coupling required for effects,

increased

involvement

pathways

The chronic nature of stroke might have

may influenced outcomes: therefore future work

allowed the plastic nature of brain to adjust to the

should examine the optimal timing, dose and

various

training tasks that might optimize the already

levels

tasks

performed

known facilitatory effects of interlimb coupling. 35

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Thus, null-hypothesis proved.

REFRENCES 1. Gresham GE, Duncan PW and Stason WB (1995). Post-stroke rehabilitation; Clinical practice guideline. [Vol. 16 AHCPR.] 2. Broeks JG, Lankhorst GJ, Rumping K and Prevo AJH (1999). The long- term outcome of arm function after stroke: results of a follow up study. [Disability and Rehabilitation (21) 357-364.] 3. Ostendorf C and Wolf SL (1981). Effect of forced use of the upper extremity of a hemiplegic patient on changes in function. Physical Therapy (61)1022-1028. 4. Morris DM and Taub E (2001). Constraint-induced therapy approach to restoring function after neurological injury. Top Stroke Rehabil (8) 16-30. 5. Senesac .D, Davis SB, Richards LG, Generalization in repetitive bilateral training in stroke. 6. Nagako Murase et al, Julie Duque et al .Influence of Interhemispheric Interactions on motor function in chronic stroke. Ann Neurol 2004; 55:400-409. 7. Patricia S. pohl, et al Carl W.Luchies et al and Pamela W. Duncan et al. Upper Extremity Control in Adults Post with Mild Residual Impairment. Neurorehabitation and neural repair,2000, Vol 14, No.1,33-41 8. D T Wade et al, V A Wood and R L Hewer et al Recovery after Stroke - - the First 3 months. Journal of Neurology, Neurosurgery and psychiatry 1985; 48:7-13. 9. Leeanne M. Carey et al, David F. Abbott and Gary F. Egan et al. Motor Impairment and Recovery in the Upper Limb after Stroke. Stroke 2005; 36:625-629. 10. Hirofumi Nakayama et al and Henrik Stig Jorgensen et al. Recovery of Upper Extremity Function in Stroke Patients: The Copenhagen Stroke Study. Arch Phys Med Rehabil Val 75, April 1994, 394-398. 11. Judith D. Schaechter et al. Motor Rehabilitation and Brain Plasticity after hemiparesis. Progress in Neurobiology Volume 73, issue 1, May 2004, 61-72. 12. Gert Kwakkel et al Robert C. Wagenaar et al and Tim W. Koelman et al. Effects of Intensity of Rehabilitation After Stroke. Stroke. 1997;28:1550-1556 13. Koichi Hiraoka et al. Rehabilitation effort to Improve Upper Extremity Function in Post Stroke Patients: A Meta Analysis. Journal of Physical Therapy Science, 2001, Vol 13; No. 1: 5-9. 14. W.R. Staines et al and W.E. Mcilory et al. Bilateral Movements Enhances ipsilesional cortical activity in acute stroke: A pilot functional MRI study. Neurology 2001;56:401-404 15. Mudie MH et al and Matyas TA et al. Can simultaneous bilateral movement involve the undamaged hemisphere in reconstruction of neural networks damaged by stroke? Disabil Rehabil, 2000 Jan 1020; 22(1-2). 16. C. L. Cunningham et al, M. E. Phillips Stoykov et al and C. B. Walter. Bilateral facilitation of motor control in chronic hemiplegic. Acta Psychologica 17. Michael I. Garry et al and Ian M. Franks et al. Spatially precise bilateral arm movements are controlled by the contralateral hemisphere. Exp Brain Res (2002) 142-:292-296. 36

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18. Lang, Catherine E et al and Wagner et al. Upper Extremity use in people with hemiperesis in the first few weeks after stroke. Journal of Neurologic Physical Therapy , Jun 2007;31: 56-63 19. Nestor A. Bayona et al and Jamie Bitensky et al. The role of task specific training in rehabilitation therapies. Topics in Stroke Rehabilitation. Aug 19, 2005 Volume 12 No.3, 58-65. 20. Fischer et al, Heidi C et al and Stubblefield et al. Hand rehabilitation following stroke: a pilot study of assisted fingure extension training in a virtual environment. Topics in stroke rehabil Jan 2007. 21. Y. Laufer et al, L. Gattenio et al and B. Sinai et al. The time related changes in motor performance of upper extremity ipsilateral to the side of the lesion in stroke survivors. Neurorehabilitation and neural repair2001 Vol 15 No.3 167-172 22. Michaelsen et al and Stella Maris et al. Specific training with trunk restraint on arm recovery in stroke: RCT. Stroke 2006 Vol 37(1) 186-192. 23. Liepert et al. Treatment induced cortical reorganization after stroke in humans. Stroke 2000, 31 12101216. 24. Timothy J. Carrroll et al and Michael Lee et al. Unilateral practice of a ballistic movement causes bilateral increases in performance and corticospinal excitability. J. Appl. Physiology 2008; 104: 16561664. 25. Carole G. Ostendorf et al and Steven L. Wolf et al. Effect of forced use of upper extremity of a hemiplegic patient on changes in function. Physical Therapy July 1981, Vol 61 No.7, 1022-1028. 26. Johanna H. Van der Lee et al and Robert C. Wagenaar et al. Forced use of the upper extremity in chronic stroke patients. Stroke 1999: 30, 2369-2375. 27. Edward Taub et al, Neal E. Miller et al and Thomas et al. Technique to improve chronic motor deficit after stroke. Arch Phys Med Rehabil April 1993; Vol 74: 347-354 28. Wolfgang H.R. Miltner et al and Monika Sommer et al. Effects of constant induced movement therapy on patients with chronic motor deficit after stroke. Stroke, 1999; 30: 586-592. 29. Steven L. Wolf et al, Carolee J. Winstein et al and Philip Miller et al and Edward Taub et al. Effect of constant induced movement therapy on upper extremity function in 3 to 9 months after stroke. JAMA 2006; 296:2095-2104. 30. Cathrin Butefisch et al and Horst Hummelsheim et al. Repetitive training of isolated movements improves the outcome of motor rehabilitation of centrally paretic hand. Journal of neurological sciences 1995; 130: 59-68. 31. Sandy McCombe Waller et al and Jill Whitall et al. Fine Motor Control in adults with and without chronic hemiperesis: Baseline comparison to nondisabled and effects of bilateral arm training. Adults. Arch Phys Med Rehabil July 2004; Vol 85: 1076-1082. 32. Dorian K. Rose et al and Carolee J. Winstein et al. Bimanual training after stroke: Are Two hands better than one? Topics in Stroke Rehabil, 2004; 11(4): 22-30. 33. Jeffery J. Summers et al, Florian A. Kagerer et al, Michael I. Garry and James H. Cauraugh et al. Bilateral and unilateral movements training on upper limb functions in chronic stroke patients; A TMS Study. Journal of Neurological sciences 2007; 252: 76-82.

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34. Jacqui H. Morris et al, Frederike van Wijck et al and Sara Joice et al. A comparison of bilateral and unilateral upper limb task training in early post stroke rehabilitation: A RCT. Arch Phys Med Rehabil July 2008; Vol 89: 1237-1245. 35. Jill Whitall et al, Sandy McCombe Waller et al and Richard F. Macko et al. Repetitive bilateral arm training with rhythmic auditory cueing improves motor function in chronic hemiparetic stroke. Stroke 2000; 31: 2390-2395 36. Andreas R. Luft et al, Sandy McCombe Waller et al and Jill Whiltall et al. Repetitive bilateral arm training and motor cortex activation in chronic stroke. JAMA October 20, 2004; Vol 292, No.15: 1853-1861. 37. Steven L. Wolf et al, Pamela A. Catlin et al and Michael Ellis et al.Assessing wolf motor function test as outcome measure for research in patients after stroke. Stroke 2001; 32: 1635-1639. 38. Pamela W.Duncan et al , Larry B. Goldstein et al and David Matchar et al. Measurement of motor recovery after stroke: Outcome assessment by Fugl Meyer Scale. Stroke 1992; 23: 1084-1089. 39. Evelyn Lee Teng et al and Helena Chang Chui et al. The modified mini-mental state (3MS) examination. J. Clin. Psychiatry 1987; 48: 314-318. 40. Janet Car, Roberta Shepherd: Bimanual Practice Neurological Rehabilitation Optimizing Motor Performance (1998;142-145) 41. Dickstein R, Hocherman S, Pillar T, Shaham, R. Three exersice therapy approaches. Physical Therapy 1986: 66; 1233-38. 42. Kelso JA, Southard DL, Goodman D. On the nature of human interlimb coordination. Science 1979; 203; 1029-31. 43. Canningham CL, Stoykov ME, Walter CB. Bilateral facilitation of motor control in chronic hemiplegia. Acta Psychol (Amst) 2002: 110: 321-37. 44. Lewis GN, Byblow WD. Neurophysiological and behavioral adaptation to a a bilateral training intervention in individuals following stroke. Clin Rehabil 2004; 18: 48-59. 45. Dorian K. Rose and Carolee J. Winstein. Bimanual training after stroke: Are two hands batter than one? Topics in stroke rehabil, 2004; 11(4):20-30. 46. Hesse S, Suhulte-Tigges G, Konard M, Baradeleben A, Werner C. Robot-assisted arm trainer for the passive and active practice of bilateral forearm and wrist movements in hemiparetic subjects. Arch Phys Med Rehabil 2003; 84; 915-920. 47. Janet Car, Roberta Shepherd: Bimanual Practice Neurological Rehabilitation Optimizing Motor Performance (1998;142-145) 48. Cauraugh JH, Kim S. Two coupled motor recovery protocols are batter than one: electomyogramtriggered neuromuscular stimulation and bilateral movements. Stroke 2002; 33: 1589-94. 49. Feydy A, Carlier R, Roby-Brami A. Longitudinal study of motor recovery after stroke: recruitment and focusing of brain activation. Stroke 2002; 33; 1610-1617. 50. Cauraugh JH, Summers JJ. Neural plasticity and bilateral movements: a rehabilitation approach for chronic stroke. Prog. Neurbio. 2005; 75: 309-20.

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51. Carson RG. Neural pathways mediating bilateral interaction between the upper limbs. Brain Res. Rev. 2005; 49: 641-62. 52. Shimizu T, Hosaki A, Hino T, Sato M, Hiraiand S. Motor cortical disinhibition in the non-affected hemisphere after unilateral cortical stroke. Brain 2002; 125; 1896-907. 53. Murase N, Duque J, Mazzocchio R, Cohen LG. Influence of interhemispheric interactions on motor function in patients with chronic stroke. Ann. Neurol. 2004; 55; 400-9. 54. Feol A, Nagorsen U, Werhahn KJ, Ravindran S, Birbaumer N. Influence of somatosensary input on motor function in patients with chronic stroke. Ann. Neurol. 2004; 56: 206-12. 55. Contralesional primary motor cortex improves hand function after stroke. Stroke 2005; 36: 1553-66. 56. Ferbert A, Vielhaber S, Meincke U, Buchner H. Transcranial magnetic stimulation in pontine infarction: correlation to degree of paresis. J. Neurol. Neurosurg. Psychiatry 1992: 55; 294-9. 57. Calutti C, Baron JC, Functional neuroimagining studies of motor recovery after stroke in adults: a

rewiew. Stroke 2003; 34: 1553-66.

CORRESPONDING AUTHOR: *PhD Research Scholar, Singhania University **Consultant Orthopaedics, Kapoor Medical Center

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A COMPARISON STUDY ON PHYSICAL IMPAIRMENTS AND FUNCTIONAL LIMITATIONS OF PATIENTS: 1 YEAR AFTER TOTAL KNEE ARTHROPLASTY VERSUS CONTROL SUBJECTS Amit Murli Patel*

ABSTRACT BACK GROUND AND PURPOSE: The purpose of this study was to examine the physical impairments and functional limitations of individuals with total knee arthroplasty (TKA), as compared with individuals with no diagnosed knee disease (control subjects). Subiects. Forty-nine individuals 1 year following TKA (30 women, 19 men) and 40 age- and gender-matched control subjects (28 women, 26 men) were assessed. METHODS: Walking speed, stair climbing ability, knee torque (in newton meters), and total work performed during 15 repeated contractions were evaluated. RESULTS: Walking speeds for men with TKA were 13% and 17% slower at normal and fast speeds, respectively. Their stair climbing ability was even more compromised (51 % slower). Walking speeds for women with TKA were 17% and 18% slower at normal and fast speeds, respectively. Similarly, their stair-climbing time was more compromised (43% slower). Men with TKA were 37% to 39% weaker and performed 36% to 37% less total work of their knee extensors compared with the control subjects. Similarly, women with TKA had knee extensor strength deficits of 28% to 29% and performed 24% less total work. CONCLUSION AND DISCUSSION: One year after TKA, marked physical impairments and functional limitations persisted. KEY WORDS: Total Knee Arthroplasty, Physical Impairment, Knee osteoarthritis, Knee Strength

the high prevalence of osteoarthritis (OA of the

INTRODUCTION

knee In India and in other industrialized nations,

been 40

1-3

and OA's severe impact on disability have

well

documented4. When conservative

Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013

management is ineffective, the surgical treatment

reduced activity consequent to OA and the TKA

of choice for individuals with severe, end-stage

may also impair function of the side without

OA is often total knee arthroplasty (TKA).

surgery.

Previous research evaluating surgical success 11-12

Jevsevar et al13 compared men and

women who had undergone TKA 1 or more years

focused on either end of the

previously with a control group of subjects with no

(impairment-disability).We

diagnosed knee disease and found that the subjects

believe that a complete description of treatment

with TKA had deficits in angular velocity during

outcome requires measures across all levels (i.e,

the stance phase while performing activities of

pathology, impairment, functional limitations, and

daily living, including walking and stair climbing.

following TKA disability

spectrum

disability) of Nagi's model of disablement .The

There is a need to document the persistent

pathophysiology of OA of the knee6 and the

physical impairments and functional limitations in

effects of alternative surgical interventions have

men and women following TKA. The direct goals

7-8

been investigated . Isolated measurements of

of physical therapy are often related to function.

impairment, including measurements of pain and

The purpose of our study was to examine the

knee range of motion (ROM), have frequently

physical impairments (knee ROM, muscle torque,

been made9. The current trend is to evaluate the

and total work) and functional limitations (walking

effectiveness of surgical interventions using

and stair climbing) of individuals 1 year after

patient-reported quality of life measures

10-12

TKA, as compared with of age

and Gender

Extensive research regarding disability has led to

matched individuals with no diagnosed knee

an appreciation of the gains expected in patient of

disease. We considered the peak torque (in newton

reported quality of life following TKA .What is

meters)

not well described in the literature is the degree of

contractions to be an indication of muscle strength.

physical impairment and functional limitation in

We considered the total work (in joules)

individuals

performed during 15 concentric contractions at

following

TKA

compared

with

individuals without knee disease. Kroll and colleagues limitations

male

during

five

angular velocities of 90˙ and 120˙/s

female

maximal

to be an

indicator of Isokinetic knee extensor and flexor

quantified functional

and

developed

endurance.

patients

preoperatively and at 5 and 13 months following TKA. They noted a reduced walking speed (22%-

Method :

16%) in patients with TKA relative to that of older

Subjects The subjects with TKA were 49 consecutive,

men with no diagnosed knee disease. Berman et 14

compared knee flexor (hamstring) muscle

consenting individuals (30 women, 19 men) who

function between limbs with TKA and limbs

had undergone TKA at a single tertiary care

without TKA. Their results suggest that maximal

orthopedic hospital. All individuals were assessed

recovery of hamstring muscle peak torque occurs

approximately 1 year after surgery (X= 12.6

by 7 to 12 months postsurgery. It may not be

months, SD= 1.5, range= 11-17). Eight of these

appropriate, however, to use the side without

individuals had bilateral knee replacements. Fifty

surgery for comparison because bilateral OA or

four similarly aged, control subjects (28 women,

all

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26 men) were recruited from the community

study, the same physical therapist using the same

through Patients relatives, working individuals etc.

goniometer assessed knee ROM. Subjects lay on a

The control subjects were free of any known knee

plinth in the supine position with the knee to be

pathology and reported no functional limitations

measured maximally flexed and the foot flat on the

during walking or stair climbing. Control subjects

plinth. Specifically, as described by Norkin and

were matched to patients with TKA based on

White24 the fulcrum of the goniometer was aligned

gender and age (± 2 years). Written informed

with the lateral midline of the femur using the

consent was obtained from each subject prior to

greater trochanter for reference. Finally, the distal

clinical testing.

arm of the goniometer was aligned with the lateral midline of the fibula using the lateral malleolus for reference. Goniometer alignment for measuring

Procedure Standardized methods for measuring weight

knee extension was identical. While in the supine

(wt) , height (ht), and girths at the waist and the

position, the knee was fully extended and a 10.2

reported a

cm (4 inch) rolled towel was placed under the

technical error of measurement of waist girth of

ankle of the lower extremity to be assessed.

0.48 cm in elderly men and of 1.15 cm in elderly

Subjects were asked to maximally straighten their

hip

were used. Chum lea et al

women. Malina et al reported a technical error of

knee, and the measurement was recorded.

measurement of hip girth of 1.23 cm for

There was no difference in height between the

intrameasurer errors. M'ilmore and Behnke19

groups. The subjects with TKA, however, were

reported

between

heavier, with higher BMI scores and greater

measurements obtained 1 day apart in young male

percentages of body fat, than the age- and gender-

correlation

0.99

subjects. Body mass index (BMI : Wt /ht ) and

matched control subjects (Table 1). Despite a

waist-to-hip ratios (WHR : waist girth/hip girth)

difference in AROM of knee flexion between

were

measurements.

groups, all Individuals with TKA had a knee

Percentage of body fat was estimated from

AROM of ≥ 90 degrees of flexion, which is

measurements of body reactance and resistance

adequate for everyday function. Similarly, subjects

obtained with a bioelectric impedance device (BIA

with TKA had an extension loss of ≤ 10 degrees,

101 Body Composition Analyzer). Muscle volume

although the men showed a difference between

of the thigh was estimated from anthropometric

groups in extension. Estimated thigh muscle

measurements using the method of Jones and

volume did not differ between groups for the men.

Pearson.20

Women with TKA had a higher estimated muscle

calculated

from

the

volume value than the women in the control group

Knee active range of motion (AROM) was

had (Table 2).

measured bilaterally, to the nearest degree, using a goniometer. It is generally reported21-23 that the

Concentric isokinetic knee torque and total

reliability of goniometric measurements improves

work were evaluated on both lower extremities

when the assessment is performed by the same

using a LIDO Active Isokinetic dynamometer.

individual, who uses the same measurement tool

Subjects with one TKA were tested so that the

with a standard test position and protocol. In our

limb that did not undergo surgery was tested first.

Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013

been reported by Patterson and Spivey 25

This limb was tested first to limit apprehension that would interfere with testing. For all other

After the subjects practiced bending and

subjects, the choice of limb to be tested first was

straightening

determined by convenience. All tests were

repetitions, they were instructed to "bend and

performed while the subjects were in a seated

straighten your knee as hard and as fast as you

position with the hips flexed to approximately 80

can" to elicit five continuous maximal voluntary

degrees. The dynamometer was preset, using

contractions of the knee extensors and flexors.

software controls, to evaluate torque (peak torque

Verbal

(developed

maximal

repeating the same phrase (ie, "kick up, pull down,

contractions) through a preset knee range of

kick up, pull down; work as hard and as fast as you

motion from 20 ± 2 to 90 ± 2 degrees of flexion in

can") during all isokinetic tests. Torque curves

the sagittal plane. The manufacturer of the LIDO

were accepted only when the coefficient of

Active system claims that the device is self-

variation for the five repetitions was less than

calibrating, and we did not test this claim. Prior to

10%. Mean peak torque (in newton-meters) was

each test session, the device is supposed to

calculated as the average of the highest torque

compensate for gravity by weighing the patient's

values for the five repetitions. Thus, the mean peak

limb through the preset range of motion at an

torque

angular velocity of 5˙/s. We did not check whether

contractions at angular velocities of 90˙ and 120˙/s

these determinations were correct. The validity

was used as an indicator of muscle strength of the

and reliability of measurements obtained with the

knee extensors and flexors.

during

five

voluntary

their

knee

encouragement

recorded

for

was

during

two

standardized

five

Table 1 Physical Characteristics and Activity Level of Study Participants by Group and Gender Control Group (n=54)

Variable Female (n = 30)

Male (n = 19)

Female (n = 28)

Male (n = 26)

Age (y)

61.3 ± 1.3

66.4 ± 1.7

61.9 ± 1.1

63.6 ± 1.4

Weight (kg)

76.0 ± 2.9

89.1 ± 3.9

64.2 ± 2.6

76.4 ± 1.8

Height (cm)

160.8 ± 1.9

170.3 ± 1.8

158.3 ± 2.1

171.5 ± 1.3

WHR

0.81 ± 0.2

0.93 ± 0.01

0.77 ± 0.01

0.93 ± 0.008

BMI (kg/m2)

29.5 ± 1.3

30.9 ± 1.4

25.2 ± 0.91

25.9 ± 0.45

Physical characteristics

concentric

LIDO Active isokinetic system have previously

TKA Group (n=49)

three

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Percentage of body

37.8 ± 2

25.3 ± 2

31.3 ± 2

21.2 ± 1

Flexion

114 ± 4.65

110 ± 3.74

143 ± 1.54

142 ± 1.16

Extension

- 1 ± 1.43

- 0.4 ± 1.18

- 7 ± 1.37

- 6 ± 0.56

23.6 ± 3.71

15.3 ± 2.23

18.2 ± 2.43

19.5 ± 1.56

fat Knee active range of motion

Total score on physical activity Questionnaire for elderly people

Table 2 Muscle Thigh Volume and Cross-sectional Area of Study Participants by Group and Gender TKA Group (n=49)

Control Group (n=54)

Variable Female (n = 30)

Male (n = 19)

Female (n = 28)

Male (n = 26)

3413.7 ± 119.8

3921.3 ± 159.9

………..

3453.7 ± 217.2

3979.2 ± 200.2

2852.7 ± 155.0

4020.0 ± 199.3

13.1 ± 0.4

13.9 ± 0.4

………..

12.7 ± 0.2

13.3 ± 0.4

11.7 ± 0.3

13.5 ± 0.2

Thigh muscle volume (cm3) Limb with TKA Limb without TKA Thigh Muscle Cross-sectional area (cm2) Limb with TKA Limb without TKA

Table 3 Knee Muscle Peak Torque (in Newton-meters) for Concentric lsokinetic Knee Extension and Flexion at an Angular Velocity of 90˙/s

Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013

TKA Group (n=49)

Control Group (n=54)

Muscle group Female (n = 30)

Male (n = 19)

Female (n = 28)

Male (n = 26)

Limb with TKA

44.8 ± 7.5

69.5 ± 8.7

…..

Limb without TKA

46.3 ± 8.1

82.6 ± 13.0

63.0 ± 3.5

113.6 ± 6.4

Limb with TKA

26.3 ± 6.9

40.0 ± 6.3

…..

Limb without TKA

31.7 ± 5.0

51.9 ± 6.8

36.0 ± 1.7

61.4 ± 2.3

Knee extensors

Knee flexors

male control subjects. At the angular velocity of

RESULT

120˙/s, knee peak torque torque of the limb with Angular velocity of 120˙/s. Compared with

the TKA of all individuals who had undergone

the angular velocity of 90˙/s, mean peak torque

surgery was diminished when compared with that

values were lower at the faster speed in all subjects except

the

women

with

TKA.

For

of the control subjects (Table 4).

these

individuals, the mean peak torques were slightly

Knee Total Work

higher for both muscle groups (extensors and

Angular velocity of at 90˙/s. Deficits in knee

flexors) on the side without the TKA and for the

extensor and flexor concentric peak torque and

knee flexors on the side with the TKA at 120˙/s

total

compared with their values at 90˙/s.

work

were

still

present

year

postoperatively, not only in the limb with the TKA but in the limb without the TKA of individuals

When assessed at the angular velocity of

who had undergone surgery.

120˙/s, knee peak torque of the women with TKA improved relative to that of the female control

On average, total work of the extensors and

subjects. For example, their limb with the TKA

flexors of the subjects with TKA was 76% to 73%,

had achieved extensor and flexor mean peak

respectively, of the values for the control subjects.

torques of 72% to 85%, respectively, of the values

Extensor endurance performance, measured as the

of the female control subjects. In the male subjects

total work of the limb without the TKA in women

with TKA, the decrement in mean peak torque

who had undergone surgery, was assessed to be

relative to that of the control subjects was

18% less than in the control subjects. Compared

markedly greater at 120˙/s than at 90˙/s. At the

with the control subjects, the performance of the

faster angular velocity, extensor and flexor mean

male subjects with TKA on muscular endurance

peak torques were just 63% to 65% of those of the

testing was generally poorer than on peak torque

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testing.

frequently reported by the subjects with TKA.

The total work of the extensors and flexors at

Persistent knee pain was reported by the subjects

90˙/s accomplished by the male subjects with TKA

with TKA following fast walking. Mean ( ± SD)

was only 64% and 55%, respectively, of that of the

pain scores were 0.8 ± 0.98 for the men with TKA

control subjects (Table 5).

and 1.8 ± 2.69 for the women with TKA, where 0 represents "no pain" and 10 represents "maximal

Angular velocity of 120˙/s. As expected, less

pain." These scores were both statistically

work was produced at the faster angular velocity

significant (P ≤ .02) and clinically significant

of 120°/s compared with the angular velocity of

compared with those of the control group.

90˙/s. This pattern was evident across both genders and groups. Similar to patterns at the slower

Stair-Climbing Performance

angular velocity of 90˙/s, deficits in total work at

Both women and men with TKA took more

120˙/s during 15 maximum repetitions were

than twice as long to ascend and descend a flight

evident in the female subjects with TKA.

of 10 stairs than it took the control subjects (Table

Specifically, they achieved 76% and 74% of the

8). Although both men and women performed at a

extensor and flexor work, respectively, of that

slower pace, the women with TKA reported a

achieved by the female control subjects. Extensor

greater perceived effort and pain in completing the

and flexor total work decrements were less in the

stair-climbing task. Although all subjects were

limb

90%,

instructed to try to ascend and descend the stairs

respectively) of the subjects who had undergone

without using a handrail, six subjects with TKA

surgery compared with the control subjects. Male

(including one subject with bilateral TKA)

subjects who had undergone surgery produced

required this assistance. All except eight subjects

similarly low extensor and flexor total work values

with TKA (including two subjects with bilateral

(63% and 57%, respectively) in the limb with the

TKA) used a reciprocal stepping pattern. One

TKA compared to the male control subjects (Table

individual declined performing this task due to

6).

fatigue.

Self- Paced Walking

Physical Activity

without

the

TKA

(87%

and

Individuals with TKA achieved over 80% of

The subjects with TKA did not differ from the

the normal and fast walking speeds of their age

control subjects in their reported total level of

and gender matched counterparts 1 year after

physical activity, as measured ( X ± SEM) using

surgery (Table 7). Ratings of perceived exertion

the physical activity questionnaire for elderly

and heart rates were similar between the groups,

people30 (19 ± 2.2 versus 19 ± 1.4, respectively).

despite the slower walking speeds at both normal

Large standard deviations for all groups indicate

and fast selected paces in the subjects with TKA.

the diverse physical activity habits of our study

A perceived exertion rating of 2, anchored by the

participants (Table. 1).

expression "slight" on the Borg Scale, was

Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013

Table 4 Knee Muscle Peak Torque (in Newton-meters) for Concentric lsokinetic Knee Extension and Flexion at an Angular Velocity of 120˙/s

TKA Group (n=49)

Control Group (n=54)

Muscle group Female (n = 30)

Male (n = 19)

Female (n = 28)

Male (n = 26)

Limb with TKA

42.6 ± 6.0

66.4 ±6.9

…..

Limb without TKA

48.8 ± 8.2

77.8 ± 10.4

59.0 ± 2.3

105.2 ±5.7

Limb with TKA

30.2 ± 6.0

40.3 ± 4.7

…..

Limb without TKA

32.3 ± 4.9

48.9 ± 4.8

35.7 ± 1.5

62.0 ±2.8

Knee extensors

Knee flexors

Table 5 Total Work (in Joules) for Concentric lsokinetic Knee Extensors and Flexors at an Angular Velocity of 90˙/s

TKA Group (n=49)

Control Group (n=54)

Muscle group Female (n = 30)

Male (n = 19)

Female (n = 28)

Male (n = 26)

Limb with TKA

621.8 ± 87.3

892.8 ± 90.7

…..

Limb without TKA

666.8 ± 112.2

1043.6 ± 133.5

816.8 ± 28.6

1397.4 ± 73.0

Limb with TKA

350.8 ± 84.7

470.9 ± 57.8

…..

Limb without TKA

430.0 ± 67.5

678.6 ± 60.0

482.5 ± 19.8

849.4 ± 31.4

Knee extensors

Knee flexors

Table 6 Total Work (in Joules) for Concentric lsokinetic Knee Extensors and Flexors at an Angular Velocity of 120˙/s

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TKA Group (n=49)

Control Group (n=54)

Muscle group Female (n = 30)

Male (n = 19)

Female (n = 28)

Male (n = 26)

523.3 ± 75.8

810.1 ± 66.7

…..

600.2 ± 112.1

934.4 ± 124.9

331.2 ± 64.8

440.0 ± 42.9

…..

401.8 ± 70.5

563.4 ± 47.6

447.9 ± 23.5

766.1 ± 32.4

Knee extensors Limb with TKA Limb without TKA Knee flexors Limb with TKA Limb without TKA

Table 7 Performance for the 160-m Walk Test at Normal and Fast Self-paced Walking Speeds

TKA Group (n=49)

Control Group (n=54)

Variable Female (n = 30)

Male (n = 19)

Female (n = 28)

Male (n = 26)

Normal self paced walking speed Speed (m/s)

1.17 ±0.05

1.31 ± 0.05

1.38 ± 0.03

1.51 ± 0.03

Pain ( 0 – 10 )

1.0 ± 0.7

0.5 ± 0.3

0.0 ± 0.0

RPE ( 0 – 10 )

1.2 ± 0.4

2.2 ± 0.4

0.5 ± 0.2

0.7 ± 0.2

Fast self paced walking speed Speed (m/s)

1.36 ± 0.1

1.53 ± 0.06

1.65 ± 0.03

1.84 ± 0.03

Pain ( 0 – 10 )

1.6 ± 0.7

0.8 ± 0.4

0.0 ± 0.0

RPE ( 0 – 10 )

1.6 ± 0.4

2.6 ± 0.5

1.6 ± 0.2

1.8 ± 0.2

Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013

Table 8 Group x Gender Performance While Ascending and Descending One Flight of 10 Steps

TKA Group (n=49)

Control Group (n=54)

Variable Female (n = 30)

Male (n = 19)

Female (n = 28)

Male (n = 26)

Stair time (s)

31.10 ± 0.49

23.33 ± 2.3

12.45 ± 0.47

11.81 ± 0.31

Pain ( 0 – 10 )

1.9 ± 1.0

0.9 ± 0.6

0.0 ± 0.0

RPE ( 0 – 10 )

2.4 ± 0.6

2.2 ± 0.4

0.4 ± 0.2

1.2 ± 0.5

DISCUSSION AND CONCLUSIONS Our

findings

indicate

that

marked

control subjects. We are unable, therefore, to

impairments and some functional limitations

delineate the effects of obesity from those of TKA

persist in individuals even 1 year following TKA.

on function.

The relative absence of pain but elevated rating of

Volunteers are known to have better health

perceived exertion and heart rate responses to

and higher functional abilities than the general

physical activity and decreased concentric muscle

population.34 The results of both the subjects with

strength suggest that physical deconditioning may

TKA and the control subjects may have been

strongly contribute to the decreased function in

influenced by this volunteer effect. The body

these individuals. Alternative explanations for the

composition

observations

although different between the subjects with TKA

composition

include or

differences

biomechanical

body

efficiency

measurements

(weight,

BMI),

and the control subjects, were similar to age and

walking between the subjects with TKA and the

gender matched normative values from a Canadian

control subjects. The subjects with TKA were

survey.16 Walking speed was within approximately

heavier (12-13 kg) and had a higher percentage of

1 standard deviation of age-predicted values for

body fat (4%-6%) compared with their age- and

men and wornen at both self-selected paces35

gender-matched control subjects. Osteoarthritis is

These comparisons suggest that our control sample

typically associated with increased body fat even

was representative of healthy older people.

in earlier stages of the disease33 but our study

Although no survey data on individuals with

provides evidence that differences persist even 1

TKA are currently available, data from other

year after TKA. The values for BMI obtained for

studies suggest that our subjects with TKA may

the subjects with TKA are associated with

have had higher than average functional levels.

increased risk of morbidity and mortality16. One of

Berman et all4 reported a normal walking speed for

the limitations of our study is that the subjects with

men and women who were tested 2 to 3 years after

TKA had increased body fat compared with the

TKA (0.90 m/s) that was slower than our mean 49

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of low intensity activities did not appear to be an

value (1.25 m/s) at the normal walking speed. 36

reported a maximal

adequate stimulus to rebuild muscle torque, total

walking speed over 4 minutes of 1.25 m/s for 12

work, or aerobic condition, nor was the resumption

men and 16 women who were tested 1 year after

of active living adequate to reduce obesity.

TKA. Free walking speed 1 year after TKA for1 7

Impairment in muscle function was evident from

men and 11 women was 1.07 m/s in the study by

the reductions in mean peak torque and total work

Kroll et al13 The higher walking speed observed

for knee flexion and extension. Force generation is

for our subjects suggests that our estimates of the

expected to decrease as the speed of movement

degree of impairment 1 year after TKA may be

increase40 but this decrease was not observed in

conservative relative to other individuals who have

our female subjects with TKA. We also expected

TKA surgery.

that functional deficits would relate to the degree

Mattsson and colleagues

Osteoarthritis is associated with altered gait 37

mechanics Previous studies

38,39

of muscle atrophy assessed by anthropometry. We

however, suggest

found no such relationship. No reduction in muscle

that biomechanical differences in gait between

volume was evident in the male subjects with TKA

subjects with TKA and subjects with no diagnosed

when compared with the control subjects, and the

knee pathology are minor. Our observation of only

female subjects with TKA had a greater muscle

minor

volume

deficits

ROM

supports

those

observations.

and

estimated

cross-sectional

area

compared with the control subjects (Table 2).

Reduced physical activity may be both a

Clinical examination of the study participants

cause and a consequence of physical impairment

ruled out thigh edema as a contributing factor.

and functional limitation. Pain associated with OA

Given Overend and colleagues' poor success in

limits physical activity, and surgical intervention

validating estimates of thigh cross sectional area

that decreases pain should allow resumption of

and volume using computed tomography (CT) in

normal activities. If reduced physical activity has

groups of young and old men41 and Sipila and

become habitual, however, this might contribute to

Suominen's finding of no relationship between

continuing obesity and deficits in physical

either cross-sectional area or lean tissue to

capacity. Our findings indicate no differences in

isometric quadriceps femoris muscle strength

total physical activity scores between subjects with

when measured by CT scan and ultrasonography

TKA and control subjects. The physical activity

in 66- to 85 year old female athletes and age-

questionnaire for elderly people30 used in our study

matched controls42 perhaps our finding is not

divides activities into low, medium, and high

surprising. The explanation for this discrepancy

categories. It was evident that few of either the

may be two fold. First, changes in intramuscular

control subjects or the subjects with TKA were

fat

active in more physically demanding activities (ie,

anthropometric measures used in our study.

sporting activities). Only 38% of the subjects with

Second, changes in neuromuscular recruitment that

TKA and only 47% of the control subjects

may alter mean torque output were not evaluated.

reported involvement in any sporting activity

would

not

detectable

with

the

Using the limb without the TKA as a control,

during the previous year. Spontaneous resumption

other

Researchers43,44

have

done,

may

Scientific Research Journal of India â&#x2014;? Volume: 2, Issue: 3, Year: 2013

subjects

underestimate the magnitude of the deficit in the l5

with

TKA

demonstrated

greater

limb with the TKA. Jevsevar et al suggested that

functional limitations on the stair climbing test,

it may not be appropriate to use the side without

with slower times and increased pain and exertion.

the TKA as a comparison because bilateral OA or

Male subjects with TKA demonstrated smaller

reduced activity consequent to OA may impair

deficits during the stair-climbing test but larger

function of the limb without the TKA. The

decreases in muscle strength and local muscular

subjects with TKA had lower peak torque and total

endurance. Performance on the SPW test at both

work values for the limb without the TKA

normal and fast paces was reduced more in the

compared with the control subjects. The reduced

female subjects, placing many more of them (62%

muscle performance may be due to continuing

at a normal pace and 31% at a fast pace, compared

effects of inactivity both before and following

with 25% and 6%, respectively, for the male

surgery or to nonsymptomatic OA of the knee

subjects) below the threshold required for safe

without the TKA. Questionnaire responses did not

crossing of street intersections. Our findings

reveal differences in physical activity between the

suggest that data for men and women regarding

control subjects and the subjects who had

walking,

undergone TKA. The absence of a difference in

concentric knee strength and local muscular

thigh cross-sectional area and estimated muscle

endurance should not be pooled.

and

OA that can be resolved successfully by surgery.45

riot explain all of the group differences (Table 2).

One year postoperatively, little pain was reported

Walking and stair climbing have been identified by clinicians and patients

performance,

Pain is a critical aspect of disability due to

volume suggests that decreased muscle size does

15,45,46

stair-climbing

in activities such as walking, stair climbing, and

critical functional activities. Our findings suggest

concentric muscle strength testing.29 Yet, in the

that although TKA is very successful in reducing

relative absence of pain, physical capacity remains

knee pain (a prime motivation for surgery),

diminished. The consequences of a diminished

patients are still limited in their functional

physical capacity are evident in slower walking

activities

speeds and a higher physiological cost demanding

compared

with

their

age-matched

counterparts. When the normal SPW speed of our

greater exertion during physical activity.

subjects with TKA was compared with the locally

The most serious consequences of reduced

required speed to cross a traffic intersection (1.2

physical capacity may be evident as aging further

m/ s )47 it became clear that a large proportion of

reduces the reserve capacity of these individuals.

these individuals (55%, n= 16) must walk at a

Adequate reserve capacity is an important factor in

faster pace than they normally use in order to

the ability of older adults to maintain their

successfully clear the intersection before the light

independence. A rehabilitation program that

changes. Indeed even at the fast walking pace,

focuses

17% (n=5) of these individuals would not be able

conditioning

to cross safely at a typical city intersection.

individuals with TKA to perform important

weight may

reduction enhance

the

and

aerobic

ability

Our analyses suggest that men and women are

activities such as walking and stair climbing. This

affected to differing degrees by TKA. Female

program may benefit patients with orthopedic

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problems in the years immediately following the

them to maintain functional independence for a

surgery and, perhaps more importantly, may also

longer period in the future.

help preserve their reserve capacity and allow

REFERENCES 1. Felsor DT, Nainlark A, Anderson J, et al. The prevalence of knee osteoarthritis in the elderly. Arthritts Rheum. 1987; 30:914-918. 2. Kovar PA, Allegrante JP, Mdckenzie CR, et al. Supervised fitness walking in patients with osteoarthritis of the knee: a randomized controlled trial. Ann Intern M P ~1.9 92;116:529-534. 3. Quam JP, Michet CJ, Wilson MG, et al. Total knee arthroplasty: a population-based study. Mayo Clin Proc. 1991; 66:589-595. 4. Verbrugge LM. Women, men, and osteoarthritis. Arthritir Cart C Research. 1995;8:2 12-220. 5. Nagi S. Disability concepts revisited: implications for prevention. In: Pope AM, Tarlov AR, eds. Disability in America: Toward a National Agenda fm Prmmtion. bvashington, DC National Academy Press: 1991:309-327. 6. Bland JH, Cooper SM. Osteoarthritis: a review of the cell biology involved and evidence for reversibility-management rationally related to known genesis and pathophysiology. Sermin Arthritis Rheum. 1984;14: 106-133. 7. Laughman RK, Stauffer RN, Ilstrup DM, Chao EYS. Functional evaluation of total knee replacement. J Orthop Res. 1984;2:307-313. 8. Andriacchi TP. Biomechanics and gait analysis in total knee replacement. Orthop Ra,. 1988;17:470473. 9. FlettJL, Burnham RS, Saboe L.et al. Effect of measurement time and mode on amount of flexion following total knee arthroplasty. Canadian Journal of Rehabililation. 1992;5:145-149. 10. Kantz M, Harris W, Levitsky K, et al. Methods for assessing condition-specific and generic functional status outcomes after total knee replacement. Med Care. 1992;30:MS240-MS2.52. 11. Ritter MA. Albohm MJ, Keating EM, et al. Comparative outcomes of total joint arthroplasty. JArthrqfdnsty. 1995;10:737-741. 12. McGuigan EX, Hozack U'J, Moriarty L, et al. Predicting quality of life outcomes following total joint arthroplasty. J Arthropla~ty. 1995;l0: 742-747. 13. Kroll MA, Otis JC, Sculco TP, et al. The relationship of stride characteristics to pain before and after total knee arthroplasty. Clin Orthop. 1989;239:191-195. 14. Berman AT, Bosacco SJ, Israelite C. Evaluation of total knee arthroplasty using isokinetic testing. Clin Orthq. 1991;271:106-113. 15. ,Jevsevar DS, Riley PO, Hodge MTA. Krebs DE.Knee kinematics and kinetics during locomotor activities of daily living in subjects with knee arthroplasty and in healthy control subjects. Phys Ther. 1993;73:229-242.

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16. Canadian Standarised Test of Fitness (CSTF) Operations .Manual. 3rd ed. Ottawa, Ontario, Canada: Fitness and Amateur Sport Canada; 1987. 17. Chumlea WC, Roche AF, Rogers E. Replicability for anthropometry in the elderly, Biol, 1984;56:329-337, 18. Malina RM, Roche AF. Manual Physical Status and Performance in Childhood, Volume 2: Physical Performance New York, NY: Plenum Publishing Corp; 1983 19. Wilmore JH, Behnke AR. An anthropometric estimation of body density and lean body weight in young women. Am J clin Nutr. 1970;23:267-274 20. Jones P, Pearson P. Anthropometric determination of leg fat and muscle plus bone volumes in young male and female adults. J Physiol Paris. 1969;294:63-66. 21. Clarkson HM, Gilewich GB. Musculoskeletal Assessment: Joint Range of Motion and Manual Muscle Strength. Baltimore, Md: U'illianis & Wilkins; 1989: 14. 22. Watkins MA. Riddle DL, Lamb RL, Personius WJ. Reliability of goniometric measurements and visual estimates of' knee range of motion obtained in a clinical setting. Phys Thrr: 1991;71:C30-97. 23. Rothstein 151. Miller PI, Roettger RF. Goniometric reliability in a clinical setting: elbow and knee measurements. Phys Thr. 1983;63:1611-1615. 24. Norkin CC, White DJ. Measurement of joint motion; A guide to Goniometry, Philadelphia PA.FA Davis Co: 1987:88. 25. Patterson LA, Spiwey WE. Validity and reliability of the LIDO Active Isokinetic svstem. J Orthop Sports Phys ther. 1992;15:32-36. 26. Bassey EJ, Fentem PH, MacDonald IC, Scriven PM. Self-paced walking as a method for exercise testing in elderly and young men. Clin Sri. 1976;31:609-612. 27. Borg GAV. Psychophysical bases of perceived exertion. Med Sci Sports Exerc 1982;14:377-38. 28. Cunningham DA, Rechnirzer PA, Donner AP. Exercise training and the speed of self-selected walking pace in men at retirement. Canadian journal of Aging 1986;5(1):12-26. 29. M. Functional Outcome measures: individuals One year post Total Knee arthroplasty Versus Healthy Controls. Toronto, Ontario, Canada: University of Toronto; 1995. Master's thesis. 30. Voorrips LE, Ravelli AC, Dongelmans PC, et al. A physical activity questionnaire for the elderly. Med Sci .Sports Exerr. 1991:23:974-979. 31. Baecke JA, Burcma J, Frijters JE. A short questionnaire for the measurement of habitual physical activity in epidemiological studies. Am J Clin Nutr 1982;36:936-942. 32. Bink B, Van der Sluys BH. Assessment of the Energy Expenditure by Indirect Time and Motion Study. In Edang EK, Anderson KL, eds. Physical Activity in Health an disease: Proceedings of the Bertostolen Symposium, Oslo Norway Oslo University; 1996:207-214. 33. Hochberg MC, Lethbridge-Cejku M, Scott WWJ, et al. The association of body weight, body fatness, and body fat distribution with osteoarthritis of the knee: data from the Baltimore Longitudinal Study of Aging. J Rheumatol. 1995;22:488-493. 34. Sackett DL. Bias in analytic research. J Chronic Dis. 1979;32:51-63.

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35. Himann JE, Cunningham DA, Rechnitzer PA, Paterson DH. Age related changes in speed of walking. Med Sci. Sports Exerc. 1988;20:161-166. 36. Mattsson E, Brostom LA, Linnarsson D. Changes in walking ability after knee replacement. Int Orthop. 1990:14:277-280 37. Messier SP, Loeser RF, Hoover JL.et al. Osteoarthritis of the knee: effects on gait, strength, and flexibility. Arch Phys Med Rehabili 1992 73:29-36. 38. Weidenhielm L, Olsson E, Brostrom LA, et al. Improvement of gait one year after surgery for knee osteoarthritis: a comparision between high tibial osteotomv and prosthetic replacement in a prospective randomized study. Scand J Rehabil Med. 1993:23:25-31. 39. Andriacchi TP. Functional analysis of pre- and post-knee surgery total knee arthroplasty and ACL reconstruction J Biomech. 1993; 115:575-581. 40. Lieber RL. Skeletal Muscle Physiology: Skeletal Muscle Structure and function- Implications for Rehabilitation and Sports Medicine. Baltimore, Md: Williams & Wilkins; 1992:60-61. 41. Overend TJ. Cunningham DA, Paterson DH. Lefcoe HS. Anthropometric and computed tomographic assessment of the thigh in young and old men. Can J Appl Physiol. 1993;18:26.3-273. 42. Sipila S, Suominen H. Knee extension strength and walking speed in relation to quadriceps muscle composition and training in elderly women. Cli11 Physiol. 1994;14:433-442. 43. Gross MT, Credle JK, Hopkins LA, Kollins M. Validity of knee flexion and extension peak torque prediction models. Phys Ther. 1990;70:3-10. 44. Krebs DE. Isokinetic, Electrophysiologic and clinical function relationships following tourniquet aided arthrotomy. Phys Thpr. 1989;69: 804-815. 45. Bellamy N, Buchanan MW. A preliminary evaluation of the dimensionality and clinical importance of pain and disability in osteoarthritis of the hip and knee. Clin Rheumatol. 1986; 5.231-241. 46. Ettinger WH, Afable RF. Physical disability from Knee Osteoarthritis; the role of exercise as an intervention. Med Sci. Sports Exerc. 1994;26; 1435-1444.

CORRESPONDING AUTHOR:

*BPT, MPT-Orthopaedics, Senior Physical therapist, Ahmedabad, Gujarat.

Scientific Research Journal of India â&#x2014;? Volume: 2, Issue: 3, Year: 2013

RESPIRATORY PHYSIOTHERAPY IN TRIPLE VESSEL DISEASE WITH POST CORONARY ARTERY BYPASS GRAFTING SURGERY (CABG) Shanmuga Raju P (MPT)*, Renkha Rao (MCh), Rajendhra Kumar J (MD), SuryaNaryana Reddy V (MS)

ABSTRACT We are presenting a case of 47 years of old female with triple vessel disease and coronary artery bypass graft surgery. Her complaint was chest pain and shortness of breath since last 5 months. Coronary angiogram revealed triple vessel disease and she underwent three coronary artery graft surgery on 24th February, 2013. Second day aftter CABG, she developed dyspnoea, reduced chest expansion and decreased arterial O2 saturation. She was treated with daily session involving positioning, chest percussion, deep breathing exercise, manual mobilization exercise and passive and active limb movements. We observed that receiving chest physiotherapy has significant effect in recovery of post CABG patient after 3 weeks of follow up. Our aim of case study is to describe effects of respiratory physiotherapy in post operative CABG in triple vessel disease. Keywords: Triple vessel disease, Coronary artery bypass grafting, respiratory physiotherapy

Approximately, one sixth of the world population

INTRODUCTION

lives in India India have 29.8 million symptomatic patients with

coronary

artery

disease

(1)

. Coronary artery bypass graft

(CABG) surgery is challenging for coronary artery

(CAD). 55

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disease. CABG is associated with an occurrence of

eosinophils 03%, monocytes 05%, basophilis 00%

pulmonary

and ESR is 30mm/1hours.

complications,

defined

any

pulmonary abnormality that occurs during the post operative period

Biochemistry: Sodium 136 mmol/L, potassium

(2)

. A decrease in pulmonary

4.1 mmol/L, chlorides 106 mmol/L, fasting serum

function is well known after open heart surgery.

glucose 103 mg/dL. Urine level is 100ml. Blood

Chest physiotherapy is routinely used in order to

group

prevent or reduce pulmonary complications after

measurements were 58 cm at axilla level, 83 cm at

surgery. Post operative treatment includes early

nipple level and, 79 cm at xiphoid level.

mobilization,

change

position,

‘O’

negative.

Chest

expansion

breathing

(3)

exercises and coughing techniques .

CASE REPORT A 47 year old female patient was diagnosed to have triple vessel disease; coronary angiogram revealed triple vessel coronary artery disease and was referred to department of cardiothoracic surgery at Chalmeda AnandRao Institute of Medical Sciences, Karimanagar on 24th February

Figure:

2013. Medical history was chest pain and

Before

CABG

and

respiratory

physiotherapy transthoracic 2D echo cardiogram

shortness of breathlessness since last 5 months.

show decrease Left ventricular systolic function

She was known case of type to II Diabetes

(LV ejection fraction (EF) 20.3 %).

mellitus, but no history of hypertension. Coronary angiogram showed triple vessel disease with left ventricular dysfunction. She underwent coronary artery bypass grafts surgery and three grafts were placed, one graft was placed to obtuse marginal 1 (OM 1), second graft was placed to left anterior descending artery and third graft was placed to right coronary artery. She was hemodynamically stable on first post operative day but on second postoperative day, she had aspirated gastric Figure:

contents and developed hypoxia due to asphyxia.

After

CABG

and

respiratory

Her blood pressure was 149/81 mm/Hg, pulse

physiotherapy transthoracic 2D echocardiogram

106 per/minute, heart rate 123 per/minute,

show improve LV systolic function (LV ejection

respiration rate 16 breaths per/minute, and

fraction 55.3 %).

temperature was 1000 F. Complete blood picture DISCUSSION

show hemoglobin 6.5 gm/cumm, WBC 5,800

Patient undergoing cardiac surgery (CS), in

cells/cumm, neutrophils 78%, lymphocytes 17%,

most number of cases post operative pulmonary 56

Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013

dysfunction developed with a significant reduction

anteroseptal wall and apical part of LV were

in lung volume, respiratory function, and lung

hypokinetic and reduced LV systolic function.

compliance and increased work of breathing

(4-5)

Second day after surgical procedure (CABG) she

Atelectasis and hypoxemia are among the main

had aspirated gastric contents and developed

pulmonary complications post operatively of

hypoxia due to asphyxia. Three week after

CABG

(6)

. Respiratory therapy is often used in the

respiratory physiotherapy treatment, her chest

prevention and treatment of post operative

expansion, arterial O2 saturation and cardiac

complications as retention of secretions, atelectasis

function were improved (EF 55%). She was

(7)

and pneumonia . In

our

case,

discharge and advised follow-up. before

CABG,

electrocardiogram shows Q wave in V1 V2 V3 &

CONCLUSION

V4 chest lead are poor progression of R wave in

Our case report showing that post operative

chest lead V5 and V6. After CABG ‘Q’ wave are

respiratory

physiotherapy

present in V1 and V4 chest lead, no new ST- T

management for a patient with coronary bypass

changes. Before surgical procedures transthoracic

graft

2D echocardiogram shown normal valves and

complications.

surgery

for

reducing

effective

pulmonary

normal size chambers. Anterior wall, lateral wall,

REFERENCES 1. Aggarwal A, Sourabh A, Goel A, Sharma V, Dwivedi S. A retrospective case control study of modifiable risk factors and cutaneous markers in India patients with young coronary artery disease. J R Soc Med Cardio 2012, vol:1(38); p: 1-8. 2. O’ Donohue WJ Jr. Postoperative pulmonary complications. When are preventive and therapeutic measures necessary? Post grad Med 1992, 91(3): 167-170. 3. Westerdahl E, Lindmark B, Almgren SO, Tenling A. Chest physiotherapy after coronary artery bypass graft surgery- A comparison of three different deep breathing techniques. J Rehab Med 2001; 33: 79-84. 4. Westerdahl E, Lindmark B, Eriksson T, Friberg O, Hedenstierna G, Tenling A. Deep breathing exercises reduce atelectasis and improve pulmonary function after coronary artery bypass surgery. Chest. 2005; 128(5): 3482-8. 5. Feltrim MIZ, Jatene FB, Bernardo WM. Em pacientes de alto risco, submetidosa’ revascularizacao do miocardio, a fisiotherapia respiratioria pre-operatoria previne as complica coes pulmonares? Rev Assoc Med Brac.2007; 53(1): 1-12. 6. Renault JA, Costa- Val R, Rossetti MB. Respiratory physiotherapy in pulmonary dysfunction after cardiac surgery. Rev Bras Cir Cardiovasc.2008; 23(4): 562-9.

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7. Lopes C, Brandao CM de A, Nozawa E, Auler Junior JOC. Benefits of non-invasive ventilation after extubation in the post operative period of heart surgery. Rev Bras Cir Cardio Vasc 2008; 23 (3): 344-350.

CORRESPONDING AUTHOR: *Dr. P. Shanmuga Raju, MPT, Asst. Professor & I/C Head, Department of Physical Medicine & Rehabilitation, Chalmeda Anand Rao Institute of Medical Sciences, Karimngar- 505001, Andhra Pradesh, INDIA. E-mail: shanmugampt@rediffmail.com

Scientific Research Journal of India â&#x2014;? Volume: 2, Issue: 3, Year: 2013

OCCUPATIONAL THERAPY MARKETING INDIAN PROSPECTIVE Koushik Sau*

ABSTRACT

OBJECTIVES: The purpose of this study is to find out the present scenario of occupational therapy marketing in India. METHODOLOGY: An author designed survey questionnaire is used for this study. Other Allied health staff, other rehabilitation staff and local occupational therapist revised the questionnaire in three stages. After the three-staged revision final survey questioners was made and send to different occupational therapist working in various parts of India. RESULT: All participants (100%) are agreeing with that there is a need of marketing. But they are not satisfied with the present marketing scenario of occupational therapy in India. CONCLUSION: This study can use by practitioner for marketing guidance KEYWORDS: Occupational Therapy, Marketing, Health Care Marketing, Occupational Therapy Marketing.

planning

1. INTRODUCTION

and

executing

the

conception,

pricing, promotion and distribution of ideas According to the American marketing

services and goods, to create exchanges that

association â&#x20AC;&#x153;Marketing is the process of

satisfy 59

individual

and

organizational

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objectives”[1] Simply “marketing consists of

according to demographic charter, political

meeting people’s needs in the most efficient

and regulatory system, socio cultural status,

and therefore profitable manner”(marketing

economical and geographical background [2].

OT Services, 1984, p.4) [2] . Marketing can

With each variation basic aim is to improve

use as medium of orientation which makes

client’s health through preventive action or

satisfying the customer’s requirements [2].

restoration of good health from a state of ill health.

Marketing beings by asking what are the requirements and desires of consumers [3].

Management of health care is becoming

Marketing also includes the analysis of the

more and more common as the demands of

competition and then decide on a positioning

cost containment are placed on providers of

plan for the product or service, in other words

care [4]. In this regards marketing can help

finding the market position, the pricing of the

health care profession. Because it is an

products and services, and then promote the

important aspect of service delivery that all

products

continue

health cares practitioners should understand it

advertising, promotions, public relations and

[5]. Of course, there is no denying that using

sales.

health information in order for healthcare

services

through

marketing does run the risk of invades privacy. Some time people thought that health

1.1 Health care marketing

care

Marketing programs sale everything in

marketing

carelessly

handled

their

today’s life including health care. Though it

sensitive information. In fact, sometimes

was once thought to be inappropriate or

health care marketing might cause shameful

unethical to use in health care professional [2].

offenses to a person's sense of independence

According to Willard and Spacksman (1993)

and self-respect. During marketing health care

health care marketing evolved in the middle of

professional should consider this aspect.

1970 when concerns arose about increased regulation of health care, decrease resources, increased

struggle

resources

and

for

change

those in

1.2 Present occupational therapy marketing

inadequate

scenario in India As occupational therapy professional we

reimbursement

should focused on the marketing for profit of

practice for health care [3].

our profession. Because all of our best efforts

The health care market is one of the most care

over more than fifty years the profession still

professional always face a challenge with

largely unknown to the general public and our

different

referral sources. Only providing good service

diagnosis. After each diagnosis there are

is not enough to grow as a profession. It needs

complicated

one

necessities

because

for

health

same

kind

requirement of various treatments planning 60

Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013

marketing strategies to develop knowledge

find out the present scenario of occupational

and faith on our profession.

therapy marketing in India and find out the

In India the health care services generally

possible procedure of occupational therapy

regulated by state government and have rights

marketing in India through open ended survey

to select service area for normal population. In

questioner.

nineteenth century scenario changed and private sector started to deliver health service

1.3 Research question What

and person starts to pay for treatment.

the

present

scenario

Changing scenario society has placed increase

occupational therapy marketing in India?

responsibility to consumers in concerning to

What are the possible procedures of marketing

their own health care choice. Challenges are

occupational therapy in India?

increasing

for

the

occupational

therapy

professional and necessary to undertake some

1.4

Objectives of the study Find

marketing strategies that help them to develop

out

the

present

scenario

awareness about occupational therapy services

occupational therapy marketing in India.

and there benefits.

Find out the possible occupational therapy marketing procedure.

Consumer goes through relative reference about the outcome of different treatment options. They rely on different information

which are getting from different source like mouth of patient, service provider, and referral

MATERIAL & METHOD

2.1 Subject:

sources etc. Marketing help occupational

Occupational

therapy profession to aware those resources

included for these study. Interns and

through valuable information. In India many

student were excluded from this study.

therapist

graduate

were

individuals and organization have been putting significant effort into creating ways to

2.2 Survey questioner:

increase the visibility and awareness of our profession but there is a lack of collective

2.2.1 Questioner development:

work. Efforts in individuals label are not

An author’s design survey questioner was

enough to overcome barriers of marketing.

used for this study [6], [7]. Questions were

Present scenario is not good for occupational

definite,

therapy professions in India they understand

structured and open ended subjective

the need but don’t know how to market the

question [7]. Same wording and ordering

profession or don’t bother to spent time for

are maintained for all target people[7].

marketing. This study is a primary effort to

Three steps were taken to modify the 61

concrete

and

pre-determined,

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question for final study. First these

percentage of respond generally less 20 to

questions were provided to five

30 percentages [6],[7] . The survey was

allied

health professional . In second stage these

mailed

questioner were provided to different

therapist throughout India After getting all

rehabilitation staff, After getting their input

the responses from respondents thank

about the clarity of the questioner such as

giving mailed was send to each participant

the wording of the questioner, grammar

separately.

usage, simplicity of questions and case of understand [6],[8] was incorporated

received. Not included 16 responses for not matching the inclusion criteria. Total

Those

121 (20.16%) responds were included for

occupational therapists were asked to complete

the

questioner

and

this study. Charterstic of respondents was

provide

provided in table 1.

comments and suggestion. Comments and suggestion

from

the

occupational

Total 137 (22.83 %) response were

stage revised questioner were send to five therapists.

hundred

3.1 Natures of respondents:

a revised survey was generated. In third

occupational

six

3. RESULT:

revise the initial draft of the questioner and

local

participant’s

Table 1 : Charterstic of respondent (N= 121)

occupational therapist were examined by the investigator and incorporate those into the revision of the questioner.

2.2.2. The final version of questioner Final version of questioner consisted two parts (see appendix). First part concerned about personal details about participant. Second part of questioner was consisted of twelve questions. It concerned about the different aspect of occupational therapy marketing procedure to frame the possible guideline.

2.2.3. Implementation procedure Survey type research study generally use large number of sample, because the

3.2 Nature of respond:

Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013

A few numbers of respondent’s (10) belief that it may not be useful.

All participants (100%) are belief that they are not satisfy with the present scenario

There are mix responses about marketing

of occupational therapy profession in India.

style. According to response individuals

All

years

marketing and group marketing both is useful

occupational therapy not captured enough

for occupational therapy profession. Most of

market in Indian Allied health

field.

the respondents (112) are thought that there

Almost all participants (114) are not

should be change in present marketing style in

presently flowing nitch marketing strategies.

context of present health care environment.

Only few (7) participants are following nitch

Some respondents (9) are not sure the change

marketing style.

is require or not in present marketing style.

were

belief

that

after

fifty

All participants are agreed in the

According to most respondents belief

point that we are able to fulfill the need sets of

electronic media is the best option for

consumer to capture rehabilitation market

promoting occupational therapy profession in

place. In case of fifth question respondents

India. But other beliefs that print media can be

responds was different. According some

also is another option. Respondent’s belief

respondents (67) All India Occupational

that, well documentation of profession is

Therapist

needful for marketing.

(AIOTA)

responsible

for

marketing our profession. Some respondents

There are so many variation is found in

(30) belief it is a responsibility of AIOTA and

the response of last question. Respondents

ACOT. Few respondents (7) belief AIOTA

suggested

brunches, occupational therapy institution

publishes in regular basis. Awareness came,

should take the responsibility. In the other

spatial clinic, speech by occupational therapist

hand some respondents (15) belief it is a duty

in local language is also help in occupational

of an individual’s occupational therapist. Two

therapy marketing. Videotapes, documentary

( 2) respondents

film can be use to promote our services, our

belief government

that

should

occupational therapy achievement. Physician

government health policy are the responsible. Every respondents are belief that our

awareness also can be use as a technique

profession should be promoted and they

because still date they are the main referral for

suggested different method for that like

our services. Some suggested there should be

formation of own council, awareness through

one liner to promote our profession.

media, pass the information through simple and

lay

man’s

word.

Most

the

4. DISCUSSIONS

respondent’s(111) belief is that, surveys is

Key finding of this study is that every

necessary for occupational therapy marketing.

participant is not satisfied about present 63

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marketing scenario of occupational therapy

procedure and easily approach to occupational

after fifty years as a profession. Though there

therapist over India.

are differences in there beliefs, marketing is

Mail were send six hundred occupational

necessary for occupational therapy in present

therapist in India. So this result cannot be

health care scenario. Without this a profession

generalized. Last limitation is respondents

can grow.

rate was (22.83 %).

We know there are no ideal strategies for marketing occupational therapy in India.

5. CONCLUSION:

Because India is country of diversity in terms of culture, language, religious. But there

In India occupational therapists are either

should be some guidance about marketing,

private practitioner or working in private

which can help a professional to capture large

sector. There a few numbers of people are

market.

working in government sector. So most of the

Through this study tried to cover most of

time we have to prove as a better treatment

the component of marketing in India through

option compare to other profession. In this

12 questions. Respondent’s provided there

regard we can use marketing for survival. This

view point regarding that. In twenty first

study can help professional in marketing

century marketing is an important aspect of

occupational therapy profession in better way.

any profession. Gradually marketing becomes common practice in health care profession

6. ACKNOWLEDGEMENT

also. This study gathered information about I want to thanks to our entire respondent

marketing can use to market our profession in

for their valuable support. I also thanks to

India. First strength of this study we use

everyone, who helped me to reevaluate

structure question to gather information from

questioner for developed final version of

sample so there is no chance of interview bias.

questioner.

Second, this study collected data from various parts of country through email so it is low cost

REFERENCES 1. Nosse. L.J., Friberg D.G., Kovacek P.R.: Markrting it’s more than selling. In : Managerial and supervisory principles for physical therapist:2nd edition: Lippincott William and wilkins.2005: 277-290 2. Jacobs K: Marketing Occupational therapy. American journal of Occupational Therapy, 1987:41:5, 315-320 64

Scientific Research Journal of India â&#x2014;? Volume: 2, Issue: 3, Year: 2013

3. Perinchief J.M: marketing: in service management: in Willard and Spackmanâ&#x20AC;&#x2122;s Occupational Therapy: 2nd edition:Philadelphia, J.B. lippincote company,1993:396-398 4. Cohn R. Strategies for positioning in the managed health care marketplace. Journal of hand therapy, 1994:7(1), 5-9 5. Jacobs k. innovational to action: Marketing occupational Therapy American journal of Occupational Therapy, 1998:52:8,618-620. 6. Lannin N. and Cusck A: factors effecting patient requirements in an acute rehabilitation: randomized control trail. American journal of occupational therapy. 2006:60, 117-181. 7. Kothari. C. R., Research methodology:methods and techniques. 2nd ed. New delhi, New age international publisher ltd. 2004: 95-117. 8. Mu. K. Lohman H. and Scheirton. L.: occupational therapy practice errors in physical rehabilitation and geriatrics setting: A national survey study.. American journal of occupational therapy: 60,288297.

APPENDIX Personal details: Participant Name & Designation: Age & Sex: Qualification: Organization name & Experience (in terms of year): Clinical experience/ teaching experience: Marketing questionnaires. 1) Are you satisfied with the present marketing scenario of occupational therapy profession in India? 2) After fifty years as a profession, has occupational therapy captured enough market in Indian rehabilitation field? 3) According to you our profession is presently following nitch marketing or any other marketing strategies in India? 4) According to you our profession is able to fulfill need sets of consumer to capture rehabilitation market place? 5) According to you who are responsible for marketing occupational therapy profession in India? 6) For marketing of occupational therapy, does it need to be promoted and if yes point out the methods of that? 65

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7) Is there any need of consumer surveys prior to marketing of the profession? 8) In the present scenario individual marketing or group marketing is essential for occupational therapy profession in India? 9) According to you with changing health care environment what modification is needed in the present marketing style? 10) According to you presently which media is effective for promoting occupational therapy marketing in India? 11) Is there any role of documentation in occupational therapy marketing? 12) According to you how occupational therapy marketing should be done in present situation in India?

CORRESPONDING AUTHOR: * Department of Occupational Therapy, School of Allied Health Science, Manipal University, Karnataka, India. Email: koushiksau@gmail.com

Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013

ANNOTATED BIBLIOGRAPHY OF STUDIES W.R.T STATISTICAL METHODS Neha Dewan*

“An annotated bibliography is a list of citations to books, articles, and documents. Each citation is followed by a succinct descriptive summary and evaluative paragraph, the annotation”. In the present article, we have provided annotated bibliography of studies from rehabilitation science that are well written with respect to (w.r.t) the statistical methods aspect of the paper. The identified studies represents a number of statistical topics addressed in the research. The purpose of present annotated bibliography is to provide the readers about the effective writing skills for representing results of statistical analysis in their research papers. The annotated bibliography mentioned below contains a brief statement of the statistical concepts effectively conveyed in the paper and a quote or two from the paper illustrating the statements which were found useful.

Bastos FN, Vanderlei LCM, Nakamura FY,

Participants : “20 young male subjects (age:

Bertollo M, Godoy MF, Hoshi RA, et al. Effects

21±2 years; height: 175±8 cm; body mass: 72±11

of Cold Water Immersion and Active Recovery

kg; body mass index: 23.5±2.1 kg·m − 2; VO2max:

on Post-Exercise Heart Rate Variability. Int J

47.1±3.1 mL·kg − 1·min − 1) were recruited for the

Sports Med. 2012; 33: 873–879.

study.”

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“Also, significant differences in the

conservative dropout of approximately 20%, we

time required to reach [Lac]peak were found

will recruit 104 subjects into the study. This

between CWI and PR (6.3±2.4 vs. 9.8±3.1 min,

sample size will yield greater than 80% power to

respectively) as well as between AR and PR

detect both statistically significant and clinically

(7.13±2.71 vs. 9.84±3.07 min, respectively)

meaningful changes in the other outcome

(p<0.05, for all)”

variables. Sample-size estimation was performed

Results:

with G*Power software, V 3.1.2.” This can be a good example of the use of descriptive

statistics

describing

This can be a good example of Sample size

study

calculation as authors have

participants as well as summarising the results.

provided

the

information required for sample size calculation 2.

Lewis JS, Wright C, Green A. Subacromial

in terms of Zα, Zβ, minimal clinical important

impingement syndrome: the effect of changing

difference(δ), standard deviation(σ) and level of

posture on shoulder range of movement. J Orthop

significance(α). Further efforts are made in

Sports Phys Ther. 2005;35:72-87.

calculating sample size by taking ‘anticipated drop out’ into consideration.

Introduction:

“The null hypotheses for this

investigation was that changing posture would

have no effect on shoulder range of movement in

al. Test-retest reliability, validity, and sensitivity

asymptomatic subjects and on shoulder range of

of the Chedoke Arm and Hand Activity

movement and pain in subjects with SIS.”

Inventory: a new measure of upper-limb function for

Barreca SR, Stratford PW, Lambert CL, et

survivors

stroke. Arch

Phys

Med

Rehabil. 2005;86:1616–1622.

This can be a good example of clearly stating Null Hypothesis.

Results: “The ICC(2,1) was .98 (95% confidence 3.

interval [CI], .96 –.99). The SE of measurement

Rhon DI, Boyles RE, Cleland J, Brown DL.

A manual physical therapy approach versus

was 2.8 CAHAI points (95% CI, 2.3–3.7)”

subacromial corticosteroid injection for treatment This

of shoulder impingement syndrome: a protocol

can

good

example

for a randomised clinical trial. BMJ. 2011; Jan

representation of Test retest reliability as

1:1(2).

authors have reported

ICC with 95% CI and

standard error. Methods: “The calculations were based on detecting a 12-point difference in the SPADI with

a standard deviation of 10 points, a two-tailed test

PW, Birmingham TB, Callaghan JP. Cumulative

and an α level = 0.05. This generates a sample

knee adductor load distinguishes between healthy

size of 43 subjects per group. Allowing for a

and osteoarthritic knees–A proof of principle

Maly

MR, Robbins

SM, Stratford

Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013

study. Gait Posture. 2012 Sep 17.pii: S0966-

Results: “Post hoc analysis revealed that the

6362(12)00318-9.

manipulative procedure produced a greater increase of PPT in both elbows as compared to

Results: “The variances of CKAL were unequal

placebo or control interventions (P<.001), and no

for the two groups. The independent samples t-

significant changes were found after the placebo

test [t = 3.97, df = 51, p = 0.001] revealed that

or control conditions (P>.6).”

CKAL was nearly two times larger in the OA group (80.80± 44.54 kNm s) compared to the healthy control group (42.79± 28.10 kNm s).” This can be a good example of Independent sample-t

test

showing

comparison

independent samples using t value with degrees of freedom and level of significance.

Wong OM, Cheung RT, Li RC. Isokinetic

knee function in healthy subjects with and without Kinesio taping. Phys Ther Sport. 2012 Nov;13(4):255-8. This can be a good example of presenting

Results: “There was no significant difference in

the conclusions of Post hoc analysis and use of

extension peak torque with and without KT and at

box plots.

different angular velocities (F(2,28) = 0.24, p = 0.79).

Similarly,

there

was

significant

difference in flexion peak torque in different 8.

conditions (F(2,28) = 0.16, p = 0.86).”

Rana Jaber, David J. Hewson, Jacques

Duchêne. Design and validation of the Grip-ball for measurement of hand grip strength. Medical

This can be a good example of Repeated

Engineering & Physics. 2012;34(9):1356–61.

measures of ANOVA as authors have reported F value with degrees of freedom and level of

Results: “A linear relationship between the two

significance.

readings can be observed (r = 0.997; 95% 7.

Fernández-de-las-Peñas C, Pérez-de-Heredia

Brea-Rivero

Miangolarra-Page

confidence interval 0.995–0.998, p < 0.05). The linear relationship between the pressure recorded

JC.

by the Grip-ball sensor and the Vigorimeter

Immediate effects on pressure pain threshold

manometer was calculated as:

following a single cervical spine manipulation in

Grip-Ball Sensor = 0.999 x Vigorimeter

healthy subjects. J Orthop Sports Phys Ther.

Manometer + 0.533 (1). The coefficient of

2007;37:325-9. 69

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determination was calculated as R2 = 0.994 (p <

than 5, we regrouped ultrasound findings into 2

0.05).”

categories and applied Fisher exact P. There was no statistically significant difference in ultrasound findings between the 2 groups (Fisher exact, P = .4209)”

This can be a good example of Categorical analysis where expected frequencies are less than 5 in which case Fisher exact P gives the exact probability of obtaining the results.

10. Cromie JE, Robertson VJ, Best MO. Work-

This can be a good example of Correlation

Related Musculoskeletal Disorders in Physical

and Regression analysis where relationship has

Therapists: Prevalence, Severity, Risks, and

been reported clearly by r value within 95% CI

Responses. Phys Ther. 2000;80(4):336-51.

and .05 as the level of significance. In addition, relationship has been presented mathematically

Results: “Male therapists had increased odds of

using regression model and percentage of

reporting neck symptoms (OR=1.9, 95% CI=1.3–

relationship has been expressed by R2.

2.9), wrist symptoms (OR=2.0, 95% CI=1.3–3.2), and thumb symptoms (OR=2.2, 95% CI=1.5–3.4)

Djordjevic OC, Vukicevic D, Katunac L,

in the last year compared with their female

Jovic S. Mobilization with movement and kinesiotaping

compared

with

colleagues.”

supervised

exercise program for painful shoulder: results of a

This can be a good example of Odd’s ratio

clinical trial. Journal of manipulative and

showing the association between gender and

physiological therapeutics. 2012 Jul;35(6):454–

prevalence of work related musculoskeletal

63.

disorders.

Results: “Because there were frequencies less

CORRESPONDING AUTHOR: * MPT, PhD Student, School of Rehabilitation sciences, McMaster University, Hamilton, ON. Email: dewann@mcmaster.ca

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