JOPSM June 2014 Volume 3, Issue 2 by adnan iftikhar

Journal of Physiotherapy & Sports Medicine (JOPSM) Volume 3, Issue 2, 2014

Editor-in-Chief

Umer Sheikh, MSc. Advancing Physiotherapy (UK), MSc. APA (Ireland/Belgium), MCSP (UK), SRP (UK), MAACP (UK), BSPT (PU), MPPS (PK) - Woking, UK

Associate Editor

Adnan Khan, MSc (UK), MCSP (UK), MICSP (Ireland), MAACP (UK), BSPT (PU) Staffordshire, UK

International Advisory Board

Editorial Board

Muhammad Atif Chishti, MSc. Musculoskeletal Physiotherapy (UK), MCSP (UK), SRP (UK), MAACP (UK), BSPT (PU), MPPS (PK) Middlesborough, UK Sameer Gohir, MSc Sports Physiotherapy (UK), MSc APA (Ireland/Belgium), MCSP (UK), SRP (UK), MISCP (Ireland), MSHC (KSA) - London, UK Rashid Hafeez M.Phil (Physiotherapy), MSc. APA (Belgium/Ireland), BSPT (PK) Dr. Fariha Shah, DPT (USA) - Lahore, PK Mohammad Bin Afsar Jan, MSPT (AUS), BSPT (PK) - Peshawar, PK

Shumaila Umer Sheikh, MSc Paediatric Physiotherapy (UK), MSc APA (Belgium/Ireland), MISCP (Ireland), BSPT (PU) - West Byfleet, UK Muhammad Atif Khan, BSc, MSc, Pgd (Ortho med), ESP, Spinal Practitioner, Berkshire, UK Muhammad Asim Ishaque, MSc Musculoskeletal Physiotherapy (UK), MCSP (UK), SRP (UK), BSPT (PK) London, UK Dr Junaid Amin DPT (PK), BSPT (PK) KSA Shahbaz Iqbal MSc Physiotherapy (USA), tDPT (USA), McKenzie Cert.

Managing Editor

Beenish Zaman, tDPT (PK), BSPT (PK) Lahore, PK

This journal subscribes to the principles of the Committee on Publication Ethics http://publicationethics.org/

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JOPSM Editorial Office | 4 Brantwood Drive, West Byfleet, Surrey, United Kingdom E-mail: info@pgip.co.uk

Journal of Physiotherapy & Sports Medicine (JOPSM) Volume 3, Issue 2, 2014 Table of Content

Editorial........................................................................................................................................01 Incidence of shoulder dysfunction in platform and springboard divers..……….…………….................04 Prevalence of Carpal Tunnel Syndrome and associated risk factors in computer users of GSM companies of Faisalabad……………………………………………...……………………………………..……………………..19 A Study on the Effectiveness of a Course of Corrective Exercises on Physical Balance in Females with Senile Kyphosis............................................………………………………………………………………..……..29 Effectiveness of Mirror Therapy to Improve Hand Functions in Stroke Patients……………………………………………………………………………...........................................................40 Osgood-Schlatter disease in a non-sporting adolescent..…………………..………………………………………..48 Role of Injection Therapy in patient with Shoulder Impingement Syndrome: A Case Study………...51 Guidelines for Authors..................................................................................................................59

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Postgraduate Institute of Physiotherapy

JOPSM Editorial Office | 4 Brantwood Drive, West Byfleet, Surrey, United Kingdom E-mail: info@pgip.co.uk

[Editorial]

Tendinopathies- A Jigsaw Adnan Iftikhar1

Physiotherapists Tendinopathies injuries

strong message to medical community to

are common in athletes but can also be

move from tendinitis to tendinopathy.

present in non-athletic patients. Tendon injuries are usually a result of overloading and overuse which become harder for tendons to stand this increasing load and lead to distinct structural changes in the tendons. These structural changes results in compromising tendonâ&#x20AC;&#x2122;s ability to sustain repeated tensile loading. The commons site for tendon injuries are mid portion or at the site of insertions. Understanding of Pathological process of tendinopathies is continuously evolving and

has

moved

from

tendinitis

inflammatory condition to a tendinopathy a degenerative condition and now a continuum theory is proposed. Historically

prior

90s

any

pain

stemming from tendon was considered as an inflammatory in nature but since histological inflammatory

data

has

chemicals

shown in

chronic

tendinopathies despite having collagen disruption and thinning1,2,3,4, it has sent a

Aftermath of dissolution of inflammatory theory , degenerative theories have gained some popularity and discussed that why tendons breakdown which may be related to vascular insufficiency which leads to hypoxic

degeneration

and

cause

disintegration of collagen matrix and considered to be

irreversible stage of

damage. At the same time it was also proposed that tendon remains in the healing phase due to persistent microdamage

and

this

inadequate

healing

process encourages increased, protein production

nerve

growths

angiogenesis

leading

vascularisation

and

neo-

disintegration

matrix5,6. The continuum theory has also gained huge attention in tendon related injuries. It has proposed three different stages with progressive

degenerative

changes

tendon which is presented individually but is linked and as the tendon passes through these changes to advance level it becomes

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Page 1

[Editorial] less likely for tendon to recover.

First

Recently it is acknowledged that there has

stage in continuum theory is reactive

been a change in attitude and terms in

tendinopathy which is a non-inflammatory

medical community to stop referring all

proliferative short term response due to

tendon injuries as tendinitis but at the same

increasing overload to the tendon in which

time they have raised their concerns when

tendon becomes thickened to increase the

referring al chronic tendinopathies as

cross sectional area to cope with the

degenerative and throw the idea of

compressive load instead of just stiffening

revisiting inflammatory component in

as in the normal tendon. The second stage

tendon injuries. With the current advances

is tendon disrepair which is similar to the

in the immunohisto-chemistry and gene

failed healing response described earlier. If

expression analysis, several studies has

continuous overloading of tendon is

shown inflammatory response both in

allowed

chronic

with

persistent

reactive

tendinopathy, it increases the chondrocytic cells, myofibroblasts and proteoglycans (protein). This increase in the proteoglycan cause further separation of matrix than the reactive stage and also encourage nerve growth

and

vascularisation

and

somewhat reduced the chances for full recovery of tendons. Degenerative stage is a further progression of the matrix disorganization and cell apoptosis. There are

large

areas

acellularity

and

disintegrated matrix filled with vessels, matrix breakdown products and little collagen. There is marked reduction in the healthy Type I fibers which are replaced by unhealthy and irregular type III fibers. With these changes there is little ability for a tendon to recover from this stage7.

tendinopathies

and

early

overloaded response . With the view of all these theories and current

evidence,

recent

tendon

symposium 2014 advocated that role of load adjustment with careful progression according to the pathological stages will remain the key treatment for tissue remodeling. It has also proposed that do not treat all tendons with same recipe due to the fact that upper limb tendons are different in their function and load as compared to lower limb weight bearing tendons. There is not great evidence for injection including PRP, high volume and corticosteroid around the tendons but still been using in the clinical practice hence should be carefully used in clinical practice9.

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Page 2

[Editorial] “At present, there is no evidence that anything

definitely

working

tendinopathy, not even surgery Prof 7.

Nicola Mafulli”

References 8. 1.

Puddu G, Ippolito E, Postacchini F. A classification of Achilles tendon disease. Am J Sports Med 1976;4:145–50. 2. Aström M, Rausing A. Chronic Achilles tendinopathy. A survey of surgical and histopathologic findings. Clin Orthop Relat Res 1995;316:151–64. 3. Józsa L, Kannus P. Histopathological findings in spontaneous tendon ruptures. Scand J Med Sci Sports 1997;2:113–18. 4. Khan KM, Cook JL, Bonar F, et al. Histopathology of common tendinopathies. 5. Update and implications for clinical management. Sports Med 1999;27:393–408.

Clancy W. Failed healing responses. In: W Leadbetter, J Buckwater, S Gordon, eds. Sports-Induced Inflammation: clinical and basic science concepts. Park Ridge,: American Orthopedic Society for Sports Medicine, 1989. Cook JL, Puram CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med 2009;43:409– 16. Rees JD, Stride M, Scott A. Tendons-time to revisit inflammation. Br J Sports Med 2013;0:1–7 3rd International Scientific Tendinopathy Symposium 2014.

Jozsa L, Kannus P. Histopathological findings in spontaneous tendon ruptures. Scand J Med Sci Sports 1997;7:113–18. Corresponding Author 1 Adnan Iftikhar Extended Scope Practitioner Connect Physical Health, Essex 36 Apex Business Village Cramlington, Northumberland, NE23 7BF E-mail: adnan.physiotherapist@gmail.com

Available online at www.pgip.co.uk/jopsm

Postgraduate Institute of Physiotherapy [Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Page 3

[Research Report]

Incidence of shoulder dysfunction in platform and springboard divers Carina, M, Andreasson, MSc1,2 and Annette, I-L M, Heijne PhD2 1

Aktiv Fysioterapi Sรถdra, Ersta sjukhus, Stockholm, Sweden Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden 2

Abstract In order for athletes to reach elite level, a high training dosage and intensity even at young age, is demanded. Although platform- and springboard diving is considered a safe sport, the inherent complexity of many maneuvers might increase the risk for shoulder-injuries. Purpose The purpose of this study was to map out the prevalence of shoulder-dysfunction

amongst divers (boys and girls, elite and non-elite). A further purpose was to examine an elite-population and to investigate the correlation between the amount of training, pain and shoulder-dysfunction. Methods A cross-sectional analytic design was used. A questionnaire was sent to 115

platform and springboard-divers between 12-18 years. Thirty-eight youths did not respond, of which nine were excluded due to previous trauma. Seventy-seven participants were included. Twelve were classed as elite-divers who underwent, in addition to fill-out the questionnaire, manual tests. Subjective shoulder-dysfunction was measured with the Shoulder Rating Questionnaire (SRQ-S). Results Shoulder-dysfunction was found amongst 12% of the total population, 8% of the

non-elite, and 33% of the elite-divers. Among the elite, 58% showed signs of shoulder-laxity when manually tested. No significant correlations were found between the amount of training and shoulder-dysfunction. A negative correlation was found between pain during training and shoulder-dysfunction, for the total population (r=-0.45), non-elite group (r=-0.37) and elitegroup (r=-0.76). Conclusion Shoulder-dysfunction was four times as likely in the elite-group compared to the

non-elite group. A strong correlation between pain during exercise and shoulder dysfunction

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Page 4

[Research Report] was found in elite-group. There was no significant correlation between the amount of training and shoulder-dysfunction. Future studies should focus on strategies for prevention of shoulder-dysfunction among platform divers. Keywords: adolescent; overuse; shoulder instability; sports injury The shoulder is a complex joint with a

Introduction

large degree of motion in multiple planes.

In order for athletes to reach elite level, a high training dosage and intensity even at young age, is demanded. Therefore, intensive pre-puberty training is common 1,24

. To reach maximum performance, the

required training is often both monotone and repetitive, increasing the risk for muscular-skeletal 1

dysfunctions .

Overuse

injuries injuries

or have

A tradeoff for this mobility is a relative lack of stability. Ligamentous laxity is not synonymous with instability. Instability is instead a functional complaint that may occur without ligamentous laxity. Most athletes with ligamentous laxity are not functionally unstable, but they may go on to develop instability with minimal injury or repetitive strain 26.

received very little attention in the sports

Congenital hyper-laxity in the shoulder

literature and there are very few studies

can also be a cause of impingement

specifically aiming to prevent overuse

syndrome 11. It has previously been shown

injuries in sport 36. Symptoms such as pain

that minor or symptom free changes in

or functional limitation most often appear

shoulder rotation, strength and limberness

gradually and therefore, according to

increase the risk for shoulder-instability 20.

Clarsen et al. 9, it is likely that athletes will

Therefore, it is of utmost importance for

continue to train and compete despite the

early diagnosis of anterior shoulder-

presence of overuse conditions.

instability 30. If untreated, there is a risk of

Overuse injuries are a common cause of shoulder-dysfunction among athletes

and are over-represented compared to 9

long-term or chronic (pain > 6 months) inflammation and pain 7. Although diving is considered a safe sport,

acute injuries . Excessive overuse of the

the

rotator-cuff and shoulder-girdle may lead

maneuvers might increase the risk of

to instability in the gleno-humeral joint,

injuries and those who dive from higher

which is a common cause of impingement

heights are more prone to injuries

inherent

complexity

many

syndrome 7,11. [Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Page 5

[Research Report] Shoulder-injuries can occur in the initial

Carter 8, shoulder-related problems can be

phase of the dive, either due to the use of

prevented through stabilization training as

the arms to generate power or rotation or

well as avoiding a too early introduction to

when starting off in a handstand

higher heights. These recommendations

However, most injuries seem to occur in

are similar to those given to swimmers by

the landing phase

. In order to soften the

landing and protect spine and neck from the axial pressure, as well as reduce splash, divers use a specific hand positioning. This special hand-grip put the shoulder in maximum flexion, internal rotation, wrist and fingers hyper-extended and pronated grip so that the palms penetrates the surface first. This is contrary to normal anatomical conditions, according to Boone and Azen 5. When hitting the water, the reaction-forces

from

the

palms

are

transmitted through the arms to the shoulder. If not considerable stability in the shoulders is present in that moment, an increased risk for shoulder-instability as well as ruptures in the rotator cuff is

Weldon and Richardson 38. In general, shoulder-dysfunction and pain was early described as common problems among athletes

. Within sports such as

swimming, gymnastics, baseball, tennis and basketball the problem is well documented

, while lacking in diving

were most studies are conducted with a biomechanical design. The purpose of this study was therefore to map out the prevalence

shoulder-dysfunction

amongst divers, elite and non-elite. A further purpose was to examine an elitepopulation

and

investigate

the

correlation between the amount of training, pain and shoulder-dysfunction.

apparent 29.

Methods

Injuries can additionally occur underneath

Study design

the water surface. This is especially true

A cross-sectional analytic design

when a backward somersault has been

Ethical approval

performed and the diver is swimming â&#x20AC;&#x153;out

The present study was approved by a local

ofâ&#x20AC;? the somersault with hyperextension in

committee consisting of senior researchers

the

spine

and

hyperflexion

the

division

physiotherapy,

shoulders. This motion increases the risk

Karolinska

for an anterior gleno-humeral subluxation

considerations of the study have followed

the recommendations of the Helsinki

but also back injuries

3,29

. According to

Institutet.

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Ethical

Page 6

[Research Report] declaration

and

the

Medical

Ethics

anonymously

during

training.

Committee.

Questionnaires were collected during five

Subjects

weeks (springtime, 2009). The divers who

One of three platform and springboard

did not respond to take part in the study

diving clubs in Stockholm were contacted

initially were reminded verbally and

and 115 youths, 12-18 years old, were

electronically continuously during the five

invited to take part in the study. Of the 115

weeks inclusion period.

youths, 13 were classified as elite divers and were asked to also undertake physical examination of the shoulder in addition to fill out the questionnaire. Youths who had difficulty in understanding Swedish, had sustained an earlier trauma to the shoulder or had undergone surgery in the shoulder, were excluded. The elite divers competed at national championship or international level, Youth European championship. In the non-elite group a majority did not compete, alternatively competed at club level. Of the 115 invited divers, 77 were included in the study. Of these, 65 were classed as non-elite and 12 as elite, who underwent, in addition to fill-out the questionnaire, the physical examination on the shoulder (Table 1).

Twenty divers were not included in the study since no written consent was received from the parents, nine declined participation

and

nine

divers

were

excluded due to previous trauma to the shoulder, see Figure 1. Evaluation

Shoulder-dysfunction

was

subjectively

estimated using the Shoulder Rating Questionnaire â&#x20AC;&#x201C; Swedish version (SRQ-S) 12,22

. SRQ-S is a validity (Cronbach

coefficient alpha 0.86) and reliability tested (test-retest, ICC 0.97), self-reporting questionnaire that consist of five subscales, reflecting

the

dysfunction

incidence

shoulder

. The questionnaire takes

approximately 5-10 minutes to fill out. The first

subscale

general

health

Coaches, divers and their parents received

assessment based on the Visual Analog

verbal as well as written information.

Scale (VAS; 0â&#x20AC;&#x201C;10 cm). The remaining

Parents were asked to provide written

four sections are pain, daily activities,

consent. In order to obtain a high level of

leisure

responders, one of the authors of this paper

work/school. These are rated on an ordinal

(CA)

the

number scale from one to five. Each

questionnaires, and these were filled in

section is summarized and the total sum is

personally

distributed

and

sporting

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

activities

and

Page 7

[Research Report] calculated by weighting the different

sitting with the arms resting in their lap

sections. A high total (100 points)

and the examiner stabilized the acromion

indicates

with one hand. When performing the

presence

shoulder-

Drawer test the examiner moves the

dysfunction. Pain was subjectively measured by Borg’s CR10 scale which is a category scale with ratio properties, suitable for determining subjective symptom as aches and pain (010) (Borg, 1990). Zero indicates no pain at all, 10 extremely painful and point corresponded to the highest degree of pain, higher than 10. Physical

humeral

head

posterior/anterior in a

gliding motion, which normally glide approximately 2-3 mm backwards and forwards. A larger movement indicates hyper-laxity

The

Drawer

test

demonstrates a high specificity 85% and a low sensitivity 53

, the inter examiner

agreement for anterior reliability is, ICC 0.53, and for posterior reliability, ICC 0.68

examination

the

. When performing the Sulcus sign the

shoulder joints in the elite-group

examiner makes an inferior traction and

Following manual tests were performed

watches for a dimpling of the skin

bilaterally, by one of the author (CA).

underneath the acromium to indicate

1) General ligament-laxity was tested according to Beighton’s mobility score, (04

9 points) (Figure 2) . The participants were asked to perform five exercises

hyper-laxity. The inter examiner reliability for Sulcus sign is reported to be ICC 0.60 34

. In this study the test was classified as

positive or negative without grading 31.

(Figure 2). If not provoking pain, each

3) Stability provocation was examined

successful exercise, gave one point per

with the apprehension and relocation test

joint. A cutoff of ≥4 points were judged as

19,21

hyper-laxity10. The Beighton score has

examiner ICC 0.47) 34 was performed with

been proven valid

The

Apprehension

test

(inter

to be used for

the participant sitting with 90° shoulder

examination of general hyper mobility in

abduction, 90° flexion in the elbow and 0°

children.

rotation. The examiner stood behind the

2) Shoulder-laxity was tested by using the Drawer test

18.31

and Sulcus sign

. The

tests were performed with the participant

participant

with

one

hand

the

acromium. With the same hand, the thumb pushed lightly on the head of the humerus while the index finger and middle finger

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Page 8

[Research Report] rested on the clavicle. With the other hand,

between the amount of training and

the

shoulder-dysfunction (SRQ-S), as well as

examiner

externally

rotated

the

participant’s arm. The apprehension test is

pain

positive if the participant experiences

dysfunction. The significance level was set

discomfort or if the examiner observes a

to p<0.05. Statistika 10.0, was used for

tendency of sub-luxation in the end-

analyses.

position

. The Relocation test (inter

examiner ICC 0.71) 34 was performed with the

participant

supine,

90°

shoulder

abduction and full external rotation and 90° flexion in the elbow. From this position, the arm is externally rotated until discomfort or apprehension is experienced and the degree of external rotation is noted. The examiner then places a hand on the anterior part of the humeral head and pushes it into the shoulder cavity. If discomfort disappears and further external rotation is possible, the Relocation test is considered positive

19,21

. The apprehension

and relocation tests are reported to have a high specificity 96% respectively 92% and a low sensitivity 72% respectively 81%, in the diagnosis of anterior instability an

individual

expresses

pain

. If

during

testing, the specificity as well as the sensitivity, is reported to be low 33.

(Borgs-CR10)

and

shoulder-

Results Shoulder-dysfunction Nine of the 77 (12%) participants in the total population scored ≤99 points with a median of 92 (range 75-99) on the SRQ-S. Five of the 65 (8%) participants in the nonelite group scored ≤99 points with a median of 96 (range 75-99) on the SRQ-S. In the elite group, four of the 12 (33%) participants scored ≤99 points with a median of 92 (range 81-99) on the SRQ-S. The remaining participants in all groups scored 100. For distribution between sexes, see Table 2. Physical

examination

the

shoulder joints in the elite-group Seven participants in the elite-group had a general hyper-laxity according to Beighton (≥4 points), see Table 1. Five of these additionally scored positive on one or more of the shoulder-laxity tests (Figure

Statistical analysis

3).

Background data are presented in actual

Seven of twelve (58%) in the elite-group

numbers and percent with the median (M)

showed signs of shoulder-laxity in the

and range. Spearman’s rank correlation

anterior Drawer test and/or Sulcus sign.

test was used to study the correlation

None of the 12 participants showed signs

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Page 9

[Research Report] of posterior laxity. One participant (8%)

the elite divers compared to non-elite

had a shoulder-instability and scored

divers.

positive on the apprehension and the relocation

test.

The

remaining

five,

showed no signs of shoulder-laxity, see Figure 3. Correlation between the amount of training and shoulder-dysfunction There was no significant correlation between the amount of training and shoulder-dysfunction

the

total

population (r=-0.14), non-elite group (r=0.02) or elite group (r=-0.02). Correlation between pain during training and shoulder-dysfunction A significant correlation (p<0.05) was found between pain during training and shoulder-dysfunction

the

total

population (r = -0.45), non-elite group (r = -0.37) and the elite-group (r = -0.76).

Discussion The principal findings in the present study were that nine out of 77 (12%), divers in the studied population reported signs of shoulder-dysfunction. Five out of 65 (8%) in the non-elite group and four out of 12 (33%) divers in the elite-group reported signs of shoulder-dysfunction according to SRQ-S, consequently, in this population, the prevalence of shoulder-dysfunction can be described as four times higher among

LĂ?nsalata et al.

reported that the

minimum clinical important difference in the SRQ-S is estimated to 2 points for each domain. There are, to our knowledge, no guidelines in terms of the cut-offs for shoulder dysfunction in the Shoulder Rating Questionnaire. Therefore, we have chosen to define all scores below 100 as shoulder-dysfunction. Such strict cut-off can be questionable, however regarding elite-performance and the high demands of training hours and present external forces in diving, it may be relevant. In the nonelite

group,

five

out

(8%)

participants reported shoulder-dysfunction, which

comparable

normal

population under 50 years old (6-11%)

and at the time of testing, the prevalence of shoulder-dysfunction in elite-divers was, 3-5 times as high 35. It was found that seven out of 12 (58%) elite-divers showed signs of shoulderlaxity when examined with the Drawer test and Sulcus sign and only one diver experienced

discomfort

the

apprehension and the relocation test. This result is supported by Emery and Mullaji 15 who tested 75 children between 12 and 18 years old with no symptoms of shoulder-

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Page 10

[Research Report] dysfunction. Fifty-seven and 48 % for

No significant correlation was found

boys and girls respectively, showed signs

between the amount of training, reported

of shoulder-laxity when examined with the

anterior/posterior Drawer test and Sulcus

according to SRQ-S. This is in contrast to

sign, despite having no symptoms

hours,

and

shoulder-dysfunction

. The

previous studies that have shown that a

most common positive test in Emery and

large amount of training increases the risk

MullajiÂ´s 15 study was the posterior drawer

of overuse injuries in the shoulders among

test, unlike the present study where no

young athletes within throwing sports,

posterior shoulder-laxity was found. These

swimmers and gymnastics

findings are in contrast in a way to our

literature it is discussed whether the

conclusions; however the tests are neither

frequency or intensity of training is

sensitive for pain or discomfort nor

important

designed to study pain. Although the elite-

symptoms2. Platform and springboard

divers did not show more signs of

diving is a sport that puts pressure on the

shoulder-laxity during physical testing

stabilizing structures in the shoulders,

compared to an age matched population 15,

when using the arms above the head, and

they reported symptoms during daily

could theoretically give similar overuse

activities

sporting

injuries as in other â&#x20AC;&#x153;upper arm sportsâ&#x20AC;?. To

activities. Taken the exposure of high

our knowledge no previous authors have

external forces in consideration, they

investigated

might be at risk for obtaining future

springboard divers, although Carter 8 noted

. Further, excessive

that the shoulder girdle is often affected in

overuse of the rotator-cuff and shoulder-

platform- and springboard diving youths,

girdle can lead to instability in the gleno-

especially in those that are diving from

humeral joint which is a common cause of

high heights. This study showed a

impingement syndrome7,11. If this scenario

significant correlation between pain during

is true for spring-board divers cannot be

training and shoulder-dysfunction (p<0.05)

concluded in the present study, instead we

in the studied population (r=-0.45), non-

suggest that longitudinal studies on a

elite group (r=-0.37) and elite-group (r=-

larger cohort will be conducted in the

0.76). This result should be interpreted

future.

with precaution since the number of

and

leisure

shoulder instability

and

factors

such

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

affecting

. In the

overuse-

correlation

Page 11

[Research Report] included subjects in these analyses was

scored high in the SRQ and this may be

low.

explained by the fact that the SRQ is less

Although several different assessment tools are available no

23,27

standardized,

shoulder

, there seems to be

universally

function

Traditionally,

the

accepted

assessment

tool.

shoulder-girdle

examined through manual tests of range of motion and strength, which is from a

sensitive for the studied population. In hindsight it may have been better to use the MISS. However, there is no Swedish, culturally adjusted version of the MISS. It might have been useful conducting a translation and validation study, before we started the present investigation.

research perspective, often unpractical and

Previous studies have shown difficulties in

time consuming. It is of great importance

diagnosing and reproducing results from

that culturally adjusted and translated

the anterior drawer tests. Ellenbecker et al.

questionnaires are used when conducting

reported

self-reporting

rater

injury

dysfunction

, when investigating the intra-

reliability

group

surveys. When starting the present study

professional baseball pitchers (18-30 years

the most valid, translated and culturally

old) a moderate to poor ICC value of 0.5.

adjusted questionnaire available was SRQ-

Relaxation

S which is a common self-evaluation

important role in allowing humeral head

assessment tool, used in research as well as

translation

in clinic

. The SRQ-S has previously

shoulders

of to

the

patient

occur

when

plays

examine

. It has been shown that The

shown good validity and reliability in

Drawer-test is more reliable with the

assessing function related disorders in the

patient in the supine position rather than

shoulder in both youth and adults

. An

sitting up right. In the anterior direction,

alternative questionnaire to the SRQ is the

the 90° abducted position is the most

Melbourne

Scale

reliable (ICC 0.72). In the posterior

that has been shown to be both

direction, the 20° abducted position is the

valid and reliable 22. The MISS has shown

most reliable, in that there was no variance

a higher grade of sensitivity in discovering

among the examiners’ results (ICC 1.0).

shoulder-instability compared to the SRQ

The 0° abducted position was the next

and may therefore indicate that the grade

most reliable test position (ICC 0.68)

of instability is underreported compared to

The test in this study was performed in

(MISS)

the SRQ

Instability

Shoulder

. The participants in this study

sitting position with the arm next to the

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Page 12

[Research Report] body and might therefore have given

the increase in participation, there has been

volitional muscular contraction or co-

a commensurate risk in the number of

contraction.

from

injuries 24. A majority of these injuries are

anterior sub-luxations can often be diffuse

due to overuse as athletes are frequently

and difficult to interpret during a manual

competing in multiple sports with year

examination

Further,

symptoms

. This may be due to the

round competition and training

. Acute

examiners experience, inconsistency in

injuries are taken care of medical staff, and

placed pressure during the test or muscle

are therefore easy to register. To be able to

tension. The elite-divers in this study had

quantify overuse problems often causing

well-muscled shoulders making the testing

pain as well as decreased performance,

more difficult and increased the risk of

novel approaches are necessary 2. In the

underreporting shoulder-laxity.

present study, we have taken the first step

For this

reason no grading was done with regards

i.e.

to the shoulder-laxity. In the literature, it is

dysfunction, in adolescent springboard

suggested that the posterior Drawer tests

divers, is present or not.

should be interpreted with caution and should preferably be done when the shoulder is anesthetized 17.

map

out

whether

shoulder-

A limitation of this study is that the main author of the manuscript was the one that carried out the physical examination of the

Instead, according to Jobe et al.

, the

elite-group; however since no previous

data regarding shoulder laxity is present in

sensitive as a positive score indicates some

the scientific literature in such cohort and

kind of pathology. Both the Drawer tests

that the test leader was unaware of the

and apprehension/relocation tests were

elite-divers

used in this study. Due to the difficulties of

understanding of the results may decrease.

using these tests, and the small number of

A further limitation is the small cohort of

participants in this study, the results from

elite-divers

the laxity-tests should be interpreted with

calculation was performed prior to the

caution.

present study and therefore no strong

apprehension/relocation

test

There has been a significant increase in youth sports participation and athletic activities over the past 3 decades

. With

before

testing,

involved.

the

pre-

power

conclusions can be drawn. Nevertheless, since reports from springboard diving, especially in terms of the upper extremity and function, are sparsely represented in

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Page 13

[Research Report] the literature this study may partly

understanding and knowledge regarding

contribute to the scientific and clinical

shoulder injury patterns, prevalence and

knowledge.

incidence,

prospective,

elite

focused studies are required.

Conclusions In the present study it was found that shoulder-dysfunction

larger,

the

Acknowledgements

studied

We thank Ersta diakoni for their grant in

population of divers (12%) is comparable

supporting this article. We are also very

to the general population, according to

grateful to the participants for sharing their

SRQ-S. However, in the elite-group,

experiences with us.

almost 33% reported signs of shoulderdysfunction compared to 8 % in the nonelite group. This might indicate that higher training intensity and thereby, in this cohort, higher training load in elite divers

References 1. 2.

has a negative effect on shoulder function. Within the elite-group 7/12 (58%) of the

participants showed signs of shoulderlaxity when examined using the Drawer test and Sulcus sign. However, only one individual experienced discomfort during

the apprehension and the relocation test. No significant correlation was found

between the amount of training and shoulder-dysfunction, while a correlation

was found between pain during training and shoulder-dysfunction. These results may be interpreted with caution since the

cohort under investigation was small. In order to determine whether a large amount of training has a negative effect on shoulder-function and to gain deeper

Adirim TA, Cheng TL. Overview of injuries in the young athlete. Sports Medicine 2003; 33(1): 75-81. Bahr R. No injuries, but plenty of pain? On the methodology for recording overuse symptoms in sports. British Journal of Sports Medicine 2009; 43(13): 966-972. Baranto A, HellstrĂśm, M, Nyman R, Lundin O, SwĂ¤rd L. Back pain and degenerative abnormalities in the spine of young elite divers: A 5-year follow-up magnetic resonance imaging study. Sports Traumatology Arthroscopy 2006; 14(9): 907-914. Beighton P, Solomon L, Soskolne CL. Articular mobility in an African population. Annals of the Rheumatic Diseases 1973; 32(5): 413-418. Boone DC, Azen SP. Normal range of motion of joints in male subjects. Journal of Bone Joint Surgery American 1979; 61(5): 756-759. Borg G. Psychophysical scaling with applications i physical work and the perception of exertion. Scandinavian Journal of Work, Environment & Health 1990; 16(1): 55-58. Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J. Chronic shoulder pain: part I: Evaluation and diagnosis. American Family Physician 2008; 77(4): 453-460. Carter RL. Prevention of springboard and platform diving injuries. Clinical Sports Medicine 1986; 5(1): 185-194.

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10.

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18.

Clarsen B, Myklebust G, Bahr R. Development and validation of a new method for the registration of overuse injuries in sports injury epidemiology: the Oslo Sport Trauma Research Centre (OSTRC) overuse injury questionnaire. British Journal of Sports Medicine 2013; 47: 495-502. Clinch J, Deere K, Sayers A et al. Epidemiology of generalized joint laxity (Hypermobility) in fourteen-year-old children from the UK. Arthritis and Rheumatism 2011; 6(9): 2819-2827. Cowderoy GA, Lisle DA, O'Connell PT. Overuse and impingement syndromes of the shoulder in the athlete. Magnetic Resonance Imaging Clinic of North America 2009; 17(4): 577-593. Dahlgren G, Hjalmarsson U, LundinOlsson L. Reliabilitetstestning av den svenska versionen av Shoulder rating questionnaire, SRQ-S. Nordisk Fysioterapi 2002; 6(3): 134–143. Dawson J, Fitzpatrick A, Carr A. The assessment of shoulder instability. The developmen and validation of av questionnaire. Journal of Bone Joint Surgery American 1999; 81(3): 420-426. Ellenbecker TS, Mattalino AJ, Elam E, Caplinger R. Quantification of anterior translation of the humeral head in the throwing shoulder: Manual assessment versus stress radiography. The American Journal of Sports Medicine 2000; 28(2): 161-167. Emery RJH, Mullaji AB. Glenohumeral joint instability in normal adolescents: Incidence and significance. Journal of Bone Joint Surgery American 1991; 73(3): 406-408. Faber KJ, Homa K, Hawkins RJ. Translation of the glenohumeral joint in patients with anterior instability: Awake examination versus examination with the patient under anesthesia. Journal of Bone Joint Surgery American 1999; 8(4): 320323. Farber AJ, Castillo R, Clough M, Bahk M, McFarland EG. Clinical assessment of three common tests for traumatic anterior shoulder instability. Journal of Bone and Joint Surgery America 2006; 88(7): 1467– 1474. Hawkins RJ, Schutte JP, Janda DH, Huckell GH. Translation of the glenohumeral joint with the patient under anesthesia. Journal of Shoulder and Elbow Surgery 1996; 5(4): 286–292.

19. Jobe FW, Kvitne RS, Giangarra CE. Shoulder pain in the overhand or throwing athlete: The relationship of anterior instability and rotator cuff impingement. Orthopaedic Review 1989; 18(9): 963975. 20. Kibler WB, Chandler TJ, Stracener ES. Musculoskeletal adaptations and injuries due to overtraining. Exercise and Sport Sciences Reviews 1992; 20: 99-126. 21. Kvitne RS, Jobe FW. The diagnosis and treatment of anterior instability in the throwing athlete. Clinical Orthopaedics and Related Research 1993; (291): 107123. 22. LÍnsalata J, Warren RF, Cohen SB, Altchek DW, Peterson MG. A selfadministered guestionnaire for assessment of symtoms and function of the shoulder. Journal of Bone Joint Surgery American 1997; 79(5): 738-748. 23. Longo UG, Vasta S, Mafulli N, Denaro V. Scoring systems for the functional assessment of patients with rotatorcuff phatology. Sports Medicine and Arthroscopy review 2011; 19(3): 310-320. 24. Mariscalco MW, Saluan P. Upper extremity injuries in the adolscent athlete. Sports Medicine and Arthroscopy review 2011; 19(1): 310-320. 25. Matsen FA, Zuckerman JD. Anterior glenohumeral instability. Clinical Sports Medicine 1983; 2(2): 319-338. 26. Nadler SF, Sherman AL, Malanga GA. Sport specific shoulder injuries. Physical Medicine and Rehabilitation Clinics of Noth America 2004; 15: 607-626. 27. Plancher KD, Lipnick SL. Analysis of evidence-based medicine for shoulder instability. Arthroscopy 2009; 25(8): 897908. 28. Richardson AB. Overuse syndromes in baseball, tennis, gymnastics, and swimming. Clinical Sports Medicine 1983; 2(2): 379-390. 29. Rubin BD. The basics of competitive diving and its injuries. Clinical Sports Medicine 1999; 18(2): 293-303. 30. Ruotolo C, Penna J, Namkoong S, Meinhard BP. Shoulder pain and the overhand athlete. The American Journal of Orthopedics 2003; 32(5): 248-258. 31. Silliman JF, Hawkins RJ. Classification and physical diagnosis of instability of the shoulder. Clinical Orthopaedics and Related Research 1993; (291): 7-19. 32. Smits-Engelsman B, Klerks M, Kirby A. Beighton score: a valid measure for

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[Research Report] generalized hypermobility in children. The Journal of Pediatrics 2011; 158(1): 119123. 33. Speer KP, Hannafin JA, Altchek DW, Warren RF. An evaluation of the shoulder relocation test. American Journal of Sports Medicine 1994; 22(2): 177-83. 34. Tzannes A, Paxinos A, Callanas M, Murell GA. An assessment of the interexaminer reliability of tests for shoulder instability. Journal of Shoulder Elbow Surgery 2004; 13(1): 18-23. 35. van der Windt DA, Thomas E, Pope DP et al. Occupational risk factors for shoulder pain: A systematic review. Occupational and Environmental Medicine 2000; 57(7): 433-442.

36. van Wilgen CP, Verhagen EA. A qualitative study on overuse injuries: the beliefs of athletes and coaches. Journal Science of Medicine Sport 2012; 15: 116â&#x20AC;&#x201C; 121. 37. Watson L, Story I, Dalziel R, Hoy G, Shimmin A, Woods D. A new clinical outcome measure of glenohumeral joint instability: The MISS questionnaire. Journal of Shoulder and Elbow Surgery 2005; 14(1): 22-30. 38. Weldon EJ 3rd, Richardson AB. Upper extremity overuse injuries in swimming: A discussion of swimmer's shoulder. Clinical Sports Medicine 2001; 20(3): 423-438.

Tables

Age Amount of training (hours/week) Years of Training M, (range) Competing divers number (Percent)

Total population (n=77)

Non-elite group (n=65)

Elite group (n=12)

Girls 53 (69%) 13 (1218) 1 (115.5) 2.75 (0.2510) 24 (45%)

Girls 46 (71%) 13 (1218) 1 (1-11)

Boys 19 (29%) 12 (1216) 1 (1-12)

Total 65

Girls 7 (58%) 15 (14-17)

Boys 5 (42%) 15 (13-17)

Total 12

13 (10-15)

2 (0.259) 17 (37%)

1 (0.57.5) 4 (21%)

2 (0.259) 21 (32%)

13.5 (1115.5) 8 (7-10)

8 (7-10)

13.25 (1015.5) 8 (7-10)

7 (100%)

5 (100%)

12 100%)

5 (4-7)

2 (4-8)

7 (4-8)

Boys 24 (31%) 13.5 (1217) 1 (1-15) 2 (0.510) 9 (38%)

Total 77 13 (1218) 1 (115.5) 2.5 (0.2510) 33 (43%)

13 (1218) 1 (1-12)

General laxity, Beighton score ď&#x201A;ł4 points, M (range)

15 (13-17)

Table 1. Background data of the involved divers, total population (n=77), girls (n=53) and boys (n=24), for the non-elite group (n=65) and for the elite group (n=12). Median and Range are shown.

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

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[Research Report]

SRQ-S â&#x2030;¤ 99 points M, (range) Number (percent)

Total population (n=77)

Non-elite group (n=65)

Elite group (n=12)

Girls 53 (69%) 88.5 (75-99)

Boys 24 (31%) 92 (89-99)

Total 77

Girls 46 (71%) 75

Boys 19 (29%) 97.5 (89-99)

Total 65

Girls 7 (58%) 81

Boys 5 (42%)

Total 12

92 (92-99)

92 (81-99)

4 (8%)

5 (21%)

9 (12%)

1 (2%)

4 (21%)

5 (8%)

1 (14%)

3 (60%)

4 (33%)

92 (75-99)

96 (75-99)

Table 2. Incidence of shoulder-dysfunction (SRQ-S) in the total population, the Non-elite group, the Elite group and the distribution between girls and boys.

Figures

115 active divers between 1218 years old were invited Non-responders, n=29

simhoppare Excluded due to previous trauma to the shoulder, n=9

Responders, n=86

In total, 77 divers included (non-elite divers, n=65 and elite divers, n=12

Figure 1. Flow chart of recruitment.

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

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[Research Report]

Figure 2. Ligomentous laxity was tested according to Beighton’s hypermobility score (0-9 points). Passive dorsal flexion of the MCP V over 90°; passive opposition of the thumb towards the forearm; hyperextension of the elbows over 10°; hyperextension of the knee over 10°; Flexion of the torso with extended knees and palms on the floor. 2 unilateral 5 positive Drawer test 7 elite-divers with positive shoulder-laxity tests

2 positive Drawer test and bilateral Sulcus sign

3 bilateral 1 positive bilateral Sulcus sign + unilateral Drawer test 1 positive bilateral Sulcus sign + bilateral Drawer test

6 negative apprehension and relocation test

1 elite-diver showed unilateral shoulderinstability at apprehension and relocation test

Figure 3. Flow diagram showing the results of the manual shoulder laxity- and instabilitytests on the elite group (n=12). Source of funding: We thank Ersta diakoni for their grant in supporting this article (Approx. 500 £) Corresponding Author

Available online at www.pgip.co.uk/jopsm

Annette Heijne, PhD, RPT, University lecturer Assistant Head of Division of physiotherapy Department of Neurobiology, Care Sciences and Society Karolinska Institutet 23 100 SE-141 83 HUDDINGE SWEDEN Phone: +46 (0)8 524 888 37 Mobile: +46 (0)70 509 48 33 annette.heijne@ki.se, ki.se © 2014 PGIP. All rights reserved.

Postgraduate Institute of Physiotherapy

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

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[Research Report]

Prevalence of Carpal Tunnel Syndrome and associated risk factors in computer users of GSM companies of Faisalabad Z Sheraz DPT¹, W Fatimah DPT², M Rauf DPT³, N Farooq DPT⁴

Abstract This study is aimed at determining the prevalence of Carpal Tunnel Syndrome (CTS) in computer users of GSM companies of Faisalabad and also to find the association between CTS development with age, gender and computer working hours through a cross-sectional study. The study includes 122 participants who were computer users and were selected through non-probability purposive sampling. Computer user aged between20-40 years were selected. Self-administered questionnaire was filled by participants that comprised of closed ended questions about the clinical symptoms of CTS. Tinel’s sign and Phalen’s test were used as diagnostic tools for the diagnosis of CTS. The prevalence of CTS among the computer users was found to be 22.1% (27 participants having CTS out of 122). Pvalue=0.780 for age showed that there was no association between age and CTS. The prevalence of CTS in females was 10.66% while it was 11.48% in males with the pvalue=0.041 which showed an association between CTS and gender. There was an association found between working hours and CTS with the p-value=0.001. The study results showed that CTS was common among the computer users of GSM companies and there was

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Page 19

[Research Report] an association between gender and working hours with CTS but no association between age and CTS. Keywords: Carpal tunnel syndrome, risk factors, clinical symptoms, prevalence, computer users, Phalen’s test, Tinel’s sign, sign and symptoms, wrist pain, mobile companies.

Introduction Carpal tunnel syndrome (CTS) is a

years of computer work and over 12 hours

musculoskeletal

work per day 2.

compression

disorder

which

neuropathy

upper

extremity occurs. CTS is characterized by the entrapment of median nerve at wrist 6. CTS symptoms consist of sensory and motor features in the median nerve territory of hand. The pattern of onset is gradual, weakness and slowness in the hand is often progressive. Pain is also a common feature which is relieved by hanging the hand. Prolonged and strenuous 24

activities are the aggravating factors . The risk factors for CTS are usually divided into occupational and individual risk factors. The individual or systemic risk factors

include

conditions

DM,

pregnancy, thyroid disorders, obesity and RA

9, 16

. Force full exertion for prolong

time due to high job exposure leads to occupation related CTS risk 9. A study conducted in 2008 showed in their results

The transmission of force from muscles to the bones occurs through long flexor tendons. The tendon gliding motion is facilitated by synovial sheath covering the tendons. These forces also act by the repetitive

use

hand

.The

pathophysiology of CTS is explained by an increased pressure in carpal tunnel which hinders the blood supply to the median nerve

. CTS is caused mainly by

frictional forces, increased pressure and nerve

injury

due

movement of wrist

the

repetitive

3, 1, 31

. It was suggested

that occupational work is the combination of different movements including wrist flexion, powerful grip, vibration and repetition. The study proved that there is significant higher risk CTS with these factors 27, 26, 21, 16.

that the prevalence of CTS is 5 % in U.S

Phalen’s and Tinel’s sign are the best

and 7 – 16% in U.K 6.The prevalence of

maneuvers among all provocative tests due

CTS among computer professionals came

to their specificity in generating median

out to be 13.1% with the higher risk in

nerve

those with high exposure that is over 8

performed by flexing the wrist against

symptoms8.

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Phalen’s

test

Page 20

[Research Report] each other with elbows in the flexion and

users participated in this study that aged

holding this position for 1 minute. The test

between 20-40 years. Individuals having

is considered positive if patient feels

systemic

numbness, tingling or pain in the median

hypothyroidism etc) or any hand deformity

nerve territory of hand. In severe cases of

were excluded. Those individuals who

CTS, symptoms occur in less than 20

were absent at the day of data collection

seconds. In Tinel’s sign, symptoms appear

and were not willing to participate were

by tapping on the median nerve with wrist

also excluded.

in neutral position, forearm supinated along with slight elbow flexion 6.

conditions

(diabetes,

Data collection tool- Data was collected

within 2 month. Self made questionnaire

Treatment can be conservative or surgical

was used.

25, 18

.The main aim of the treatment is to

Rationale of self made questionnaire–

resolve symptoms and preserve hand

Many questionnaires were available but

movements14. Tendon gliding exercises

none

give better results as compared to nerve

objectives because those questionnaires

them

matched

with

study

Ergonomic

were based on sign and symptoms,

management can be done to reduce the

symptoms severity and functional status of

symptoms by minimizing the movement 5.

hand. Whereas, the present study aimed at

Ergonomic keyboard give better results as

finding the prevalence and association of

compared to placebo keyboard and it is

age , gender, working hours, phalen’s test

concluded that symptoms are relieved by

and tinel’s sign with

exercises17.

gliding

CTS among GSM

. Surgical treatment

companies. Self made questionnaire was

is also used for CTS. Through surgery the

formed after consulting different studies in

space

literature.

ergonomic keyboard of

increases

and

thus

The

idea

selection

compression over median nerve resolves.

questions was taken from the following

For intermediate to intense CTS, surgery is

studies.

advised 18.

Self made questionnaire consist of three

Methodology:

parts i.e.

this

Cross-sectional

survey,

non-

probability purposive sampling was used for sampling in computer users of GSM companies of Faisalabad. 122 computer

First part consist of demographic details (name, age, gender, work settings)16. Second questions

part

consists

regarding

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

of their

different work

Page 21

[Research Report] experiences, working hours, break times, 16

and that privacy of the participants would

break duration and hand dominancy .

be maintained.

Third part consist of questions regarding

Data analysis- Data analysis was done

presence of pain, numbness, tingling ,

through SPSS 16.0 version to analyze the

distribution of symptoms in different areas

prevalence of CTS among computer users

of hand and the last two questions were

of GSM companies. Chi-square test was

about two tests performed on participants

applied to find the association between

such as Tinel’s sign and Phalen’s test on

age, gender and working hours where 0.05

which basis participants were evaluated

is set as a P-value.

for presence of CTS11.

Results:

Diagnostic criteria- The diagnosis of CTS

based on the findings of phalen’s test and tinel’s

sign.

phalen’s considered

test

and

agreement tinel’s

according

between sign

was

that

the

individuals having positive tinel’s sign will have 78% chances of having positive Phalen’s test. (Table 01). Reliability- The sensitivity and specificity

of the Phalen’s test was 10-90% and 33100% respectively. The sensitivity and specificity of Tinel’s sign was 77% and 50% respectively 20. Ethical issues- Permission from the

Ethical Committee of The University of Faisalabad, Pakistan was taken before the conduction

data

collection.

Furthermore, considering ethical issues informed consent was taken from higher authorities of GSM companies (franchises) and from individual participants as well. The participants were ensured that it would not cause any harm to them or their jobs

The prevalence of CTS came out to be 22.1%. The overall mean of age group was 25.93±4.610 s.d. In present study, 68% were males and 31.9% were females. The prevalence in male was 11.48% and in female was 10.66%. So males are more prevalent in having CTS as compared to females. In case of association between gender and CTS, P-value is less than 0.05 so it is statistically significant. In age groups, there was higher prevalence of CTS in age group 20-30 as compared to 31-40.In case of association between age group and CTS P-value is greater than 0.05, so it

statistically insignificant. The prevalence of CTS was higher in those individuals who worked for more than 6 hours and P value of working hours and CTS is less than 0.05, so this value is statistically significant.

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Page 22

[Research Report] While present study results show that the

Discussion There are many studies about prevalence of CTS in different populations but less data is available on CTS prevalence in computer professionals. According to one study, the prevalence of CTS in computer users was found to be 13.1%. In this study 648 subjects were selected and studied, those

participants

were

computer

professionals of total 21 companies

Another study on computer professionals had the prevalence rate of 3.5%

According to present study results, the prevalence of CTS in computer users of GSM companies is 22.1%. Thus present study results reveal that prevalence of CTS is greater in computer users with the previous studies. It indicates that the

participants who work for more than 6 hours per day have greater risk of developing CTS as compared to 12 hours per day according to the previous studies. Present study is somehow consistent to previous

study

but

with

the

slight

difference in the working hours. This difference can be explained by the reason that we have taken the maximum amount of hours as more than 6 hours which cannot be specified. It can include either 7 or 12 hours. As the hours are not specified so the results can be supportive or opposite to the previous study on computer users and

requires

further

research

association between working hours and CTS.

occurrence of CTS become more prevalent

The risk of CTS in females was twice as

now a days and has become a matter of

compare to that in the males. The study

great concern for computer users. While

revealed that females who do moderate

on the other hand the prevalence rate of

manual work were more likely to develop

3.5% is much contradictory to 22.1% as

CTS while males who do heavy manual

the former study used nerve conduction

work were more prone to CTS

study as the confirmatory tool which is

According to another study, prevalence of

gold standard as compared to this study

CTS in males was 1.56%. While the

using Phalenâ&#x20AC;&#x2122;s test and tinelâ&#x20AC;&#x2122;s sign as the

prevalence of CTS in females was 35.93%

confirmatory test.

According to a study results, risk of development of CTS was greater in participants who used to do computer work for more than 12 hour per day 2.

. Another study shows that CTS is more

prevalent in male i.e.14.5% than females i.e.6.8%

owing

their

greater

involvement in administrative work 2. In this study there are total 83 males and 39

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Page 23

[Research Report] females. The prevalence of CTS in females

the risk of CTS is more owing to

is 10.66% while the prevalence of CTS in

degenerative changes and less data is

males is 11.48%. This shows that our

available on adult population regarding

results are not consistent with the previous

CTS. This poses a need for further

studies as previous studies were based on

research in the adult population regarding

the general population19, 10 compared to the

CTS.

present study where computer using population is studied. So occupational variations are seen. While the study

supports result as their work is also on computer users showing that computer usage is an important risk factor for CTS.

The presence of sensory and motor symptoms in patients diagnosed with CTS was described in different studies. In a study, the prevalence of sensory and motor symptoms was found to be as 56% and 48%

respectively.

Sensory

symptoms

There were many studies which indicated

include pain, numbness, tingling and in

that incidence and severity of CTS

more severe cases hand weakness whereas

increases with the advancing age. A study

motor symptoms include hand movement

on participants in which severity of CTS

in-coordination and hand shaking both.

with increasing age was determined by

The result of this study revealed that 50%

abnormal findings of nerve conduction

of motor symptoms were present in

studies. As the person grows old, the

problematic hands

difference in latencies was higher which

more than 50% individuals with CTS

indicated that the problem was severe 7.

described

There is another research that focused on

median

the association between age and CTS; it

numbness and night pain were strong signs

revealed that risk of CTS was higher in

of CTS

people aged above 55 years

numbness nerve

In another study, and

territory.

tingling

Presence

. Present study reveals that the

. Present

prevalence of pain, numbness and tingling

study concludes that there is no association

in CTS is 55.56%, 51.85% and 51.85

between age and CTS. Present study

respectively. It is consistent with the

results are inconsistent with the results of

previous studies because these symptoms

previous studies because age range taken is

almost always occur with the hand

between 20-40 years which includes the

problems more specifically CTS and

adult population while the previous studies

diagnosis is usually made by considering

worked over elderly population in which

clinical symptoms as well.

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Page 24

[Research Report] Conclusion

Limitations

In according to our study results, CTS is a

Study cannot be generalized to other cities

significant

computer

of Pakistan. Few franchises have policies

workers of GSM companies (franchises) of

that didnâ&#x20AC;&#x2122;t allow them to share their

Faisalabad. Prevalence of CTS was found

information. Because of high workload

to be 22.1% in our study. Our results

and extreme busy routines some of the

reveal that the workers who use computer

franchise workers were unable to share

for more than 6 hours in a sustained wrist

their information. Incorrect addresses of

posture are at a greater risk of developing

franchises at internet. Some franchises

CTS. Regarding gender differences, males

workers

are more prone to this problem as compare

standardize

to females. Age has no significant impact

according to our research aims.

problem

among

on CTS. So workshop should be arranged at district level about the awareness of hand posture and managing ergonomically. The present study, statistically significant

found after 6 weeks of treatment. Simple 3.

serial measurement levels during the fracture healing process in combination

with clinic-radiological examination can be an additional, useful, reproducible, patient-clinical friendly and cost effective

tool in predicting whether fractures are at

risk of developing complications like

delayed union/non-union and in aiding the clinician to intervene properly at an appropriate.

not

cooperative.

questionnaire

was

No found

References

improvement in RUST score has been diaphyseal, fresh traumatic fractures, the

were

Davis Alfonso, C., Jann, S., Massa, R., Trreggiani, A., (2010). Diagnosis, treatment and follow up of the carpal tunnel syndrome: A review. Neurol Sci. 31 (3): 243-52. Ali, K.M., Sathiyasekaran, B.W.C., (2006). Computer Professionals and Carpal Tunnel Syndrome (CTS). International Journal of Occupational Safety and Ergonomics (JOSE). 12(3): 319-325 Amirlak, B., Upadhyaya, K., Ahmed, O., Wolff, T., Tsai, T., Scherker, L., (2010). Median nerve entrapment. Internet communication. Anon., 2014. Sample size methodology. MaCorr Research. [online] Available at: <http://www.macorr.com/sample-sizemethodology.htm> Anthony, J., (2003). Management of carpal tunnel syndrome. Am Fam Physician. 68 (2): 265-72. Aroori, S., Spence, R.A.J., 2008. Carpal tunnel syndrome. Ulster Med J, 77 (1): 6-17. Bodofsky, E.M., Wu, K.D., Campellone, J.V., Greenberg, W.M., Tomaio, A.C., (2005). A sensitive new median-ulnar technique for diagnosing mild carpal tunnel syndrome. ElectromyogClinNeurophysiol. 45 (3): 139-44. Bruce, F.M.D., Ron, G.M.D., Leake, P., (2004). Diagnosis, causation and treatment of carpal tnnel syndrome: an evidence based assessment. Worker compensation BoardAlberta.

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

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[Research Report] 9.

10.

11.

12.

13.

14. 15. 16.

17.

18.

19.

20.

Burt, S., Deddens, J. A., Crombie, K., Jin, Y., Wurzelbacher, S., Ramsey, S., (2013). A prospective study of carpal tunnel syndrome: Workplace and individual risk factors. Occup Environ Med. 70 (8): 568-74 De-Krom, M.C., Knipschild, P.G., Kester, A.D., Thijs, C.T., Boekkooi, P.F., Spaans, F., (1992). Carpal tunnel syndrome: prevalence in general population. J ClinEpidemiol. 45 (4): 373-6. Eleftheriou, A., Rachiotis, G., Varitimidis, S., Koutis, C., Malizos, K. N., Hajichristodoulou, C., (2012). Cumulative keyboard strokes: A possible risk factor for carpal tunnel syndrome. J Occup Med Toxicol. 7 (1): 16. Gerr, F., Marcus, M., Ensor, C., Kleinbaum, D., Cohen, S., Edwards, A., Gentry, E., Ortiz, D. J., Monteilh, C., (2002). A prospective study of computer users: 1. Study design and incidence of musculoskeletal symptoms and disorders. Am J Ind Med. 41 (4): 221-35. Goodwin, S., Burch, J., (2003). Save your hands carpal tunnel syndrome and related conditions are easier to prevent than cure. Massage and Body work. Gorsche, R., (2001). “Carpal tunnel syndrome.” Canadian Journal of CME. 13 (10): 101-20. Gupta, S.K., Benstead, T.J., (1997). Symptoms experienced by patients with carpal tunnel syndrome. Can J Neurol Sci. 24 (4): 338-42. Harris, A. C., Eisen, E. A., Dale, A. M., Evanoff, B., Hegmam, K. T., Thiese, M. S., Kapellusch, J. M., Garg, A., Burt, S., Bao, S., Silverstein, B., Gerr, F., Merlino, L., Rempel, D., (2013). Personal and workplace psychosocial risk factors for carpal tunnel syndrome: A pooled study cohort. Occup Environ Med. 70 (8): 529-37. Horng, Y.S., Hsieh, S.F., Tu, Y.K., Lin, M.C., Horng, Y.S., Wang, J.D., (2011). The comparative effectiveness of tendon and nerve gliding exercises in patients with carpal tunnel syndrome: a randomized trial. Am J Phys Med Rehabil. 90 (6): 435-42. Ibrahim, I., Khan, W.S., Goddard, N., Smitham, P., 2012. Carpal Tunnel Syndrome: A Review of the recent literature. The Open Orthopaedic Journal. 6 (Suppl 1: M8): 69-79. Lam, N., Thurston, A., (1998). Association of obesity, gender, age and occupation with carpal tunnel syndrome. Aust N Z J Surg. 68 (3): 190-3. MachDermid, J.C., Wessel, J., (2004). Clinical diagnosis of carpal tunnel syndrome: a systematic review. J Hand Ther. 17 (4): 30919.

21. Maghsoudipour, M., M oghimi, S., Dehghaan, F.,Rahimpanah, A., (2008). Association of occupation and non-occupational risk factors with the prevalence of workrelated carpal tunnel syndrome. J OccupRehabil. 18 (2): 1526. 22. Martinez-Albaladejo, M., Nombela-Gomez, M., Perez-Flores, D., 1995. With respect to Tinel’s and phalan’s signs. An Med Interna. 12 (1): 21-4. 23. O’Connor, D., Page, M.J., Marshall, S.C., Massy-Westropp, N., (2012). Ergonomic positioning or equipment for treating carpal tunnel syndrome. Cochrane Database Syst Rev. 18; 1 24. Palmer, P. K. T., (2011). Carpal tunnel syndrome: the role of occupational factors. Best Pract Res ClinRheumatol, 25 (1): 15-29. 25. Prime, M. S., Palmer, J., Khan, W. S., Goddard, N. J., (2010). Is there light at the end of the tunnel? Controversies in the diagnosis of carpal tunnel syndrome. Hand (N Y). 5 (4): 354-60. 26. Shiri, R., Miranada, H., Heliovara, M., ViikariJuntura, E., (2009). Physical work load factors and carpal tunnel syndrome: A population based study. Occup Environ Med. 66 (6): 36873. 27. Spahn, G., Wollny, J., Hartmann, B., Schiele, R., Hofmann, G. O., (2012). Meta-analysis for the evaluation of risk factors for carpal tunnel syndrome part 2. Occupational risk factors. Z OrthopUnfall. 150 (5): 516-24. 28. Tamburin, S., Cacciotori, C., Marani, S., Zanette, G., (2008). Pain and motor function in carpal tunnel syndrome: a clinical, neurophysiological and psychophysical study. J Neurol. 255 (11): 1636-43. 29. Thomas, J., Haverbush, M.D., n.d. frequency of carpal tunnel syndrome in computer users. Online orthopeadic medical article. [online]. Available at: www.orthopsurgeon.com 30. Uchiyama, S., Itsubo, T., Nakamura, K., Kato, H., Yasutomi, T., Momose, T., (2010). Current concepts of carpal tunnel syndrome: Pathophysiology, treatment, and evaluation. J OrthopSci 15: 1-13. 31. Werner, R. A., Andary, M., (2002). Carpal tunnel syndrome: pathophysiology and clinical neurophysiology. Clinneurophysiol. 113 (9): 1373-81.

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

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[Research Report] Tables & Graphs Phalen’s test Positive Positive Negative

Total

Negative

Total

102

122

Table no. 1: Phalen’s and tinel’s test agreement – Agreement = (10+85)/122 = 77.9% Approx. 78%

CTS Prevalence ( %)

P- value

Gender Male Female

11.48 10.66

0.041 ----

Age group (years) 20-30 31-40

20.4 1.64

0.865 ----

Working hours 1-2 hours 2-4 hours 4-6 hours >6 hours

1.64 4.1 2.4 13.93

0.001 ----

Table no 2: Prevalence of CTS as per age, gender and working hours

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

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[Research Report]

Graph No. 1 Prevalence of CTS in computer users of GSM companies in Faisalabad

Corresponding Author Zainab Sheraz¹ Doctor of Physiotherapy, The University of Faisalabad. Pakistan Email: zainab.48@hotmail.com Contact: +923017070941 Wajeeha Fatimah² Doctor of Physiotherapy, The University of Faisalabad. Pakistan Email: wajeeha_049@live.com Contact no: +923046298281 Mahum Rauf³ Doctor of Physiotherapy, The University of Faisalabad. Pakistan Email: mahum61@gmail.com Contact no: +923350793401 Nida Farooq⁴ Doctor of Physiotherapy, The University of Faisalabad. Pakistan Email: nidafarooq696@hotmail.com Contact no. +923247780710 © 2014 PGIP. All rights reserved.

Available online at www.pgip.co.uk/jopsm

Postgraduate Institute of Physiotherapy

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

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[Research Report]

A Study on the Effectiveness of a Course of Corrective Exercises on Physical Balance in Females with Senile Kyphosis Noshin ghamari1, Yahya sokhanghoyi2, Zinat Nik Ayin3, Morteza Jourkesh4

Abstract Objective: Balance and rehabilitating balance has become a subject of great significance for

researchers since imbalance is one of the major reasons behind falls among the elderly. The present study aims to study the eight-week course of corrective exercises on females with senile Kyphosis. Methodology: 36 females with senile Kyphosis in experimental and control groups. Both groups were given the Berg Balance Scale pre and post corrective exercises while the experimental group was given a second test after an exercise-free month. The corrective exercises were done within three sessions a week for eight weeks, each session lasting for an hour. Findings: the results of the independent t-test indicated that balance in the experimental group had improved significantly after a course of corrective exercises (pâ&#x2030;¤0.05). Also, there was a significant difference between the post test and the post exercisefree month test in the experimental group (pâ&#x2030;¤0.05).Conclusion: corrective exercises can significantly affect balance in females with senile Kyphosis by reducing their chances of falling. Nevertheless, the effects of such exercises lack durability after the exercise-free

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

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[Research Report] period. The corrective exercises can be recommended as an effective therapy to improve balance in females with senile Kyphosis. Keywords: senility, corrective exercises, balance, Kyphosis.

posture is determined by the shaping of

Introduction Mortality rates have dropped by means of today’s medical, economical, and social advances as life expectation is peaking. The earth’s population is moving towards senility rather than youth. The 60-year-old and older population accounts for the most growing

demographic

the

world.

According to the predictions of United Nations, the population of people over 60 will be five times, and those over 80 seven times the population of other age groups in the world, meaning that in every 7 people, one will be older than 60 8. Posture will consequently be affected

as the aging

anteroposterior (AP) curvatures of the spine. Incorrect habit of posture and excessive overload of the spine lead to diseases

and

pain

complaints.

Body

posture changes during the course of ontogenesis and is subject to deterioration in later period of life. It is related to the ageing process of one’s body, which is a result of decreasing one’s physical fitness, which is visible in reducing one’s muscle strength, reducing the bone mass, worse nerve muscle coordination, suppleness and balance, or involutional changes in the ligamentous joints apparatus 18.

process modifies the normal posture and

Natural

often results in curved posture 13.

depends on the function of its muscle,

Body posture is characterized by enormous changeability and depends on many different factors, such as e.g. age, sex, general

health,

type

occupation,

physical activity, and circadian rhythm. Body posture is related to the physical state of an individual, and it is conditioned by one’s efficiency of the kinetic sense, muscular

balance

coordination

17.

and

muscle

nerve

The quality of body

alignment

spinal

column

bone and joint structural. This weakness of spinal column extensor muscles can cause to static, dynamic and stature unbalance in persons that called faulty posture. It is caused unfavorable status on mental, social and physiological Function of person

Physiological

disorders

caused

unfavorable physical status are serious. Increasing back curve of thoracic area recognized as kyphosis 20.

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

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[Research Report] 26

Among the deformities of the spine in

may be appropriate

sagittal plane, kyphosis is one of the most

exercises for elderly people, emphasis

important cases in the study of postural

ought to be put on increasing flexibility

control from the mechanical standpoint

and strengthening muscles

Because The smallest deviation of upper

exercises are considered to be of great

limb, that is almost 60 percent of total

remedial value to postural abnormalities.

body weight in standing position, causes

Coordinating

Displacement of body center of mass to

muscles

forward And finally will Causes weaker

stretching activities, corrective exercises

balance

are able to treat dorsal kyphosis, scoliosis

performance

kyphotic

individuals compare to healthy one

and

. In a programme of

agonist

through

lordosis.

27.

Corrective

and

antagonist

strengthening

and

precise,

Hyperkyphosis, an exaggerated curvature

corrective exercises involve strengthening,

in the thoracic spine, is commonly

stretching and neuromuscular facilitation

observed in the older population although

exercises. As corrective exercises involve

its causes have not been well investigated.

physical activities and bodily movement,

Greater degrees of kyphosis impairs

they are regarded, in most body of study

physical function

22,23

and well-being , and

increases load on the vertebral bodies

that potentially could increase the risk for vertebral compression fractures. A recent study

confirms

comprehensive

the

need

assessment

for of

more health

outcomes in older adults with greater degree of kyphosis. Hyperkyphosis is considered a problem that primarily affects older women, even though the prevalence of hyperkyphosis in older men is estimated to range from 15-40%, depending upon how kyphosis is defined 25.

conducted in the field, as improving body posture 28. Senile Kyphosis is one of the phenomena that

occur

particularly

the

spinal

curvature,

Thoracic

curvature,

through the aging process 3. Studies show that rounding of the Kyphosis curve is in direct relationship with declined physical functioning, balance disorder, walking deceleration, reduced functional capability, and reduced ability to do daily house chores

activities

. Aging and reduced physical lead

disorders

all

Regular physical activity is very important

physiological functions such as sensory-

for health; however, in case of elderly

motor

people, not every form of physical exercise

postural control in older adults and

functions,

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

and

can

decreased

Page 31

[Research Report] increased likelihood of injury 9. Declined

73.78Âą10.532 years of age, 63.60Âą5.987

balance and postural control in older adults

kilograms of weight, and 153.22Âą9.707

following certain complications or resulted

centimeters of height were selected, and

by the aging process have adverse effects

randomly divided into experimental and

such as falling, an incidence that may

control groups. The entrance criteria to the

result in various physical, psychological,

study required women of 60-90 years of

and social problems and inabilities, as well

age with a Kyphosis angle of more than 40

as decline performance and independence

degrees, and lack of potentially intervening

in activities of daily living, and eventually,

special medical conditions. The screening

cause death. It is prevalent among %30 of

process

the population over 65 years of age 7.

questionnaires and medical history forms

Sheikh Poor (2012) studied the effects of exercise therapy on older adults with Kyphosis which concluded its positive and significant effectiveness on balance. By performing aquatic exercises, Resende (2008) also found improvement in balance among older adults 15. Based on the importance of independence and balance control in motion among senior adults, and checking the durability of such exercises, the present research was conducted to study the effectiveness of a course of selected corrective exercises on balance in females with senile Kyphosis.

Methodology The present study is a quasi-experimental research with pre-post test design, and an experimental group as well as a control group. 36 females with senile Kyphosis and averages and standard deviations of

consisted

cognitive

filled prior to the study. At first, the object and method of the study as well as the ethical considerations were fully explained to the subjects, after which all the subjects read and signed the consent forms to enter the experiment. The proper method of the experiment was shown and clarified pictorially by the experimenter. The subjects were given pretests using the Berg Balance Scale. This scale consists of 14 functional activities performed by an elderly subject where the experimenter registers the corresponding score for each activity. The maximum score on this scale is 56

11.

The training program of the

experimental group included two months of corrective exercises, the first month of which required 40 minute sessions and the second month 60 minutes ones. In each month, 10 minutes of the total time were spent warming up, 10 minutes were spent

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Page 32

[Research Report] cooling down, and the rest of the time was

course after a month. The data was

allotted to the main activities which started

registered in SPSS20, and the research

off light and gradually picked up.

hypothesis was studied using statistical

The performed strength and stretching exercises were as follows: 1. Raising arms with elbows straight and palms facing each other. 2. Shrugging while keeping arms at shoulders

normality

data

distribution,

and

independent and paired t-tests to examine research hypotheses). Findings

The descriptive data of the subjects such as

both sides. 3. Pulling

tests (Kolmogorov–Smirnov test to check

back

while

keeping elbows bent.

age, weight, and height are shown in table 2 by group divisions. The findings of Berg Scale indicated a significant difference in scores of balance in pre and post tests of the experimental group (p≤0.05) (table 3). Moreover,

there

was

significant

difference (P≤0.05) in comparison of the balance score between the experimental and control groups shown in table 4. It is noteworthy that the average and standard deviation after an exercise-free month shown in table 5 indicates a significant difference which specifies non-durability of the corrective exercises after an exercise-free month.

Discussion and Conclusion The present research aimed to study a After completing the exercise course, both groups were given a post test. A second test was given to the experimental group in order to examine the durability of the

course of corrective exercises on the balance of females with senile Kyphosis. The study results confirmed the study hypothesis that 8 weeks of corrective

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Page 33

[Research Report] exercises are effective on females with

Also,

senile Kyphosis. The positive effects of

conducted a research titled “the effects of

corrective exercises on balance in the

exercises with mini trampoline on dynamic

experimental group pre and post test are

balance in older females of Tehran” where

seen in table 3 according to the findings.

they reported that such exercises show

Furthermore, the same results are offered

significant difference in evaluation of

when

and

dynamic balance among older adults in all

experimental groups (table 4). However,

8 directions of the Star Excursion Balance

the corrective exercises lack durability

Test 1.

after an exercise-free month as evident in

research titled “the effects of a 6 week

table 5.

course of functional exercises on static and

The

comparing

potential

the

reasons

control

behind

this

improvement might include strengthening the lumbar muscles, enhanced flexibility, and enhanced proprioception as well as enhanced physical state of the subjects, all of which lead to improvement in motor skills that brings about self confidence and removes fear of falls. The selected corrective exercises may have improved

Hanachi

Kaviani

(2010)

In 2009, Sadeghi et al did a

dynamic balance in older males”. They reported no significant difference between the experimental and control groups in pre tests of the Sharpened and Rhomberg Test to measure static balance and Timed Up and Go Test to measure dynamic balance. However, the experimental group had a better performance compared with the control group on the final test 6.

posture and subsequently balance by

Mirafzal et al (2011) investigated the

strengthening antigravity muscles and

effect of three non-invasive and active

increasing flexibility in anterior upper

methods on static and dynamic balance of

body muscles. Moreover, it is probable

kyphotic adolescent. Based on results, they

that the exercises affected proprioception.

concluded that taping and corrective

These findings are consistent with those of a study by Sheikh Poor et al (2012) that was carried out as a course of exercise

exercises have a positive effect on kyphosis correction and this point can be considered in ameliorating programs.

therapy on posture and balance in females

There are so many researches that reported

with senile Kyphosis resulting in a

balance declining following deformities

significant and positive effect of such

21,29

courses on elderly adults with Kyphosis 5.

postural control in patients with kyphosis

. Anbarian compared the features of

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Page 34

[Research Report] and control groups and founded that Static

balance.

balance can be disturbed with change in

inconsistence is perhaps the type and

line with normal spinal alignment, but this

nature of exercises and number of training

clearly and firmly, affected with the ability

sessions as well as physical fitness of the

to make dorsal spinal deformity reduces

subjects 2.

the dynamic balance control

. Related to

this point it can be noted that a kyphotic individual have a more instability as a result of tribulation in base of support and they turn to compensatory mechanisms for balance maintaining. This can be explained with this point that following a deformity in the spine in sagittal plane, body's center of gravity changes its location to forward and downward and consequently the whole body center of mass moved forward and downward and main outcome of this process is balance instability 30.

The

reason

behind

this

Yung-Hui & Kuei-Fu (2008) carried out a study titled “The Relationships between Physical Activity and Static Balance in Elderly

People”

significant

reporting

difference

lack

between

static

balance and levels of physical activity as well as between static balance and types of physical activity. However, static balance with open eyes was significantly superior to static balance with eyes closed

Douris et al (2003) carried out a research titled “The effect of land and aquatic exercise on balance scores in older adults”

Resende et al (2008) conducted a research

and observed no significant difference

titled “Effects of hydrotherapy in balance

when using exercises in water rather than

and prevention of falls among elderly

on land, while balance was improved after

woman”

exercises in both conditions 12.

claiming

that

hydrotherapy

significantly increases balance among elderly women and decreases the risk of falling

. The results of the present study

are inconsistent with the research by Khaje Nemat et al (2014) where they studied the effects of strength exercises on static balance in healthy elderly males. Khaje Nemat has used the Sharpened and Rhomberg Test and Timed Up and Go Test to measure static and dynamic

Azizi et al (2012) conducted a research titled effect of 8 weeks specific corrective exercise in water and land on the angle of kyphosis and some pulmonary indices in kyphotic students and According to the results The research shows there is an important decrease in kyphosis angle after a particular corrective aquatic and land exercise in both groups (aquatic exercise group and land exercise group).Siavash

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Page 35

[Research Report] Dastmanesh et al (2013) carried out a

females and males, but did not affect

study titled Relationship Between Physical

balance control since postural spasms had

Fitness Abilities,Trunk Range of Motion

worsened

and Kyphosis in Junior High School

unaffected in females10. Improving posture

Students

reporting that decrease in the

and physical functioning is one of the most

strength of erector spine muscles and

prominent objects of corrective exercises.

scapular abductors and also decrease in the

Therefore, based on the results of the

flexibility of trunk flexors and scapular

present study, such exercises can be

flexors may increase the level of thoracic

employed in an effective method to

kyphosis.

improve and prevent disorders in balance

The

negative

relationship

between kyphosis strength of erector spine muscles can be justified by the reduced ability of these muscles for creating the necessary torque to maintain the upright

decrease in the ability of this muscle to the

spinal

column

not

sufficiently supported by the erector spine

muscles, leading to the load and weight of the upper body on

inactive organs

(including ligaments, bones, cartilages,

etc.). This loading can increase the length of erector spine muscles and lead to increased kyphosis 31,32. In a research titled â&#x20AC;&#x153;effects of a short â&#x20AC;&#x201C;

term dynamic balance training program in healthy older women", Bellew et al (2003) reported that primary compatibilities in amount and severity of strength exercises led to increased leg strength in healthy

and

remained

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Hanachi, Parichehr, Kaviani, Gelareh, 2010,The Effects of Exercises with Mini Trampoline on Static Balance in Elderly Females of Tehran, Medical Magazine of Hormozgan, year 14, Issue 2, pg: 148-155. Khaje Nemat, Karrar, Sadeghi, Haydar, Sahebozamani, Mansoor, 2012, The Effects of 8 Weeks of Strength Exercises on Static and Dynamic Balance of Healthy Males, Sports Medicine Magazine, Year 6, Issue 1, pg: 4555. Daneshmandi, Hassan, Alizadeh, Mohammad Hossein, Gharakhanloo, Reza, 2005, Corrective Exercises, Third Print, The Orgazination of Studying and Editing University Books of Humanitis (SAMT), pg: 11-152. Shavandi, Nader, Haydarpoor, Shahnaz, Sheikh Hosseini, Rahmatollah, Rahman, 2011, The Effects of 7 Weeks of Corrective Exercises on Thoractic Kyphosis in Students with Hyperkyphosis, Medical Sciences Magazine of ShahreKord, Year 13, Issue 4, pg: 44-50. Sheikh Poor, Layla, 2012, The Effects of a Course of Exercise Therapy on Posture and Balance in Females with Senile Kyphosis over 60 year old, The School of Physical Education and Sport Science of Western Tehran Islamic Azad University. Sadeghi, Haydar, Noroozi, HamidReza, Karimi Asl, Akram, Montazer, Mohammad Reza, 2009, The Effects of 6 Weeks of Functional Exercises on Static and Dynamic Balance in Healthy Elderly Males, Iran Elderly Magazine, Year 3, Issue 8, pg: 565-570.

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18. 19. 20. 21.

Fallah Poor, Mandana, Joghtayi, Mohammad Taghi, Ashayeri, Hassan, Salavati, Mahayar, Hosseini, Ali, 2003, A Study on the Effects of Mind Exercises on Balance among the Elederly, Rehabilitation, Year 4, Issues 14 and 15, pg: 34-38. Selected Results of Census of People and Houses, Year 2005, Iran Statistics Center. Letafat Kar, Khodadad, Bakhsheshi, Mahdi, Ghorbani, Sohrab, 2010, Corrective and Medical Exercises, Second Print, Bamdad Publications, pg: 73-187. Bellew JW, Click Fenter P, Chelette B, Moore R, Loreno D. (2002). "Effects of a short – term dynamic balance training program in healthy older women". J of Geriatric Physical Ther, 28. pp: 01-05. Conradsson M, Lundin-Olsson L, Lindelöf N, Littbrand H, Malmqvist L, Gustafson Y, Rosendahl E. Berg balance scale: intrarater test-retest reliability among older people dependent in activities of daily living and living in residential care facilities.Phys Ther 2007; 87: 1155-1163 Douris p, et al, 2003,The effect of land and aquatic exercise on balance scores in older adulths, Geriatric phys Ther , 26(1), p:3-20. Judge . J, et al, 1993, Balance Improvements in older women: Effects of Exercise Traninig, Journal of the American Physical Therapy Association, P:254-262. Martha. R. Hinman . EdD . 2004, Comparison of thoracic Kyphosis and Postural Stiffness in younger and older women, The Spine Journal, P: 413-417. Resende SM et al, 2008, Effects of hydrotherapy in balance and prevention of falls among elderly woman. Rev Bras Fisioter, 12(1) , P:57-63 Yung-Hui, T, Kuei-fu.L, 2008 , The Relationships between Physical Activity and Static Balance in Elderly People, J Exerc Sci fit , P:21-25. Anwajler J., K.Barczyk, D.Wojna, B.Ostrowska, T.Skolimowski (2010) Characteristics of body posture in the sagittal plane in elderly people — residents of social care centres. (In polish. engl. Abstract). Gerontol. Pol.,8(3): 134-139. Grabara M., J.Szopa (2011) Habitual body postu-re and mountain position of people practicing yoga. Biol.Sport, 28: 51-54. Nitzschke, E., & Hildenbrand, M. (1990). Epidemiology of kyphosis in school children. Z Orthop Ihre Grenzgeb, 128(5), 477-481. weakness of expiratory muscles (Taheritizabi et al., 2012) Taheritizabi, A., Mahdavinejad, R., Azizi, A., Jafarnejadgero, T., & Sanjari, M. (2012).

22. Investigation of sagittal curves of spinal column and establishing the norm of thoracic kyphosis and lumbar lordosis. World Journal of Sport Sciences. 6(1), 80-83. 23. Anbarian. M.. Mokhtari. M.. Zarei. P & Yalfani. A. (2008). The Comparison of postural control characteristics in people with kyphosis and control group. Scientific Journal of Medical Sciences of Hamadan University. Volume XVI, No. 4.. pp: 53-60. 24. Huang MH KW, Cummings SR, Kado DM:Hyperkyphosis and decline in functional status in older community dwelling women: The Study of Osteoporotic Fractures in ASBMR. 2010. 25. Katzman WB,et al:Kyphosis and Decline in physical function over 15years in older community-dwelling women: the study of osteoporotic fractures.J Gerontol A Biol Sci MedSci2013,68(8):976–983. 26. Bruno AG,et al:The effect of thoracic kyphosis and sagittal plane alignment on vertebral compressive loading.J Bone Miner Res2012,27(10):2144–2151 27. Katzman W,et al:Association of Spinal Muscle Composition and Prevalence of Hyperkyphosis in Healthy Community-Dwelling Older Men and Women.J Gerontol A Biol Sci Med Sci2012,67(2):191–195 28. Kraemer J.M., D.Marquez (2009) Psychosocial correlates and outcomes of yoga or walking among older adults. J. Psychol.,143(4): 390– 404 29. Jachimowicz V., T.Kostka (2009) Association be-tween physical activity and functional and motor abilities among the elderly. Pol. J. Sport. Med.,25(4): 256-264. 30. Meyer DW. Correction of spondylolithesis by the correction of global posture. Clinical Chiropractics[serial online]. 2001; 22-23. Available from: http://www. idealspine.com /pages/ajcc/ajcc -new/july2001/ pdf/ meyer%207%2001.pdf. Accessed April 21, 2011. 31. Durmus. B.. Altay. Z.. Ersoy. Y.. Baysal. O & Dogan. E. (2010). Postural stability in patients with ankylosing spondylities. Disabil Rehabil. 32(14):1156-62. 32. Bot. S. D. M.. Caspers. M.. VanRoyen. M. C. Toussain. H. M & Kingma. I. (1999). Biomechanical analysis of posture in patients with spinal kyphosis due to ankylosing spondylitis. pilot study. Rheumatology (Oxford). 38(5):441-3. 33. Arshadi, R., A. Asghari, M. Hashemi and M. Imanzadeh, 2010. Study of the Correlation Between Degree of Kyphosis and Lordosis with Spinees' Flexibility.World Applied Sciences Journal,9(5): 521-525.

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

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[Research Report] 34. Cheshomi, S., R. Rajabi and M.H. Alizadeh, 2011.The Relationship Between Thoracic Kyphosis Curvature, Scapular Position and Posterior Shoulder

35. Girdle Muscles Endurance.World Applied Sciences Journal, 14(7): 1072-1076

Tables Time Segmentation Duration of Each (Monthly) Exercise (Second) First

Second

First two weeks Second two weeks First two weeks Second two weeks

Repetition

Exercise Length (Minute)

5-6

10-13

40’

7-8

17-21

40’

25-28

60’

Table 1 Timing the Exercises

Group

Age (Year)

Height (Centimeter)

Weight (Kilogram)

Experimental

70.278±8.88

154.97±7.951

65.72±12.150

Control

77.28±11.13

151.47±11.148

61.47±19.210

Table 2 Descriptive data of the Subjects

Index

Group

Average

Standard Deviation

Statistical value of T

Degree of Significance Freedom Level

Balance Pre intervention Post intervention

47.556 53.611

6.289 3.867

-6.027

0.001>

Table 3 Comparing the Average Scores of Balance of the Experimental Group Pre and Post Corrective Exercises

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Page 38

[Research Report] Index

Group

Balance Control Experimental

Average

Standard Deviation

Statistical value of T

Degree of Significance Freedom Level

37.772 53.611

4.750 3.867

-11.005

0.001>

Table 4. Comparison of the Balance Scores between the Experimental and Control Groups after the Corrective Exercises

Index

Group

Average

Balance

Post intervention 53.611 A month post 50.055 intervention

Standard Deviation

Statistical value of T

Degree of Significance Freedom Level

3.867 4.721

4.507

0.001>

Table 5. Comparison of the Balance Scores of the Experimental Group after the Corrective Exercises and after an Exercise-free Month

Corresponding Author Noshin ghamari1, Yahya sokhanghoyi2, Zinat Nik Ayin3, *Morteza Jourkesh4 E: jourkesh_2006@yahoo.com 1,2 Faculty of Physical Education and Sportst Science, ,Islamic Azad University, Central Tehran Branch, Iran;2Department of Physiotherapy, University of Social Welfare and Rehabilitation Sciences,Tehran,Iran ;4Department of Physical Education and Sports Science, Shabestar Branch, Islamic Azad University, Iran ÂŠ 2014 PGIP. All rights reserved

Available online at www.pgip.co.uk/jopsm

Postgraduate Institute of Physiotherapy [Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Page 39

[Research Report]

Effectiveness of Mirror Therapy to Improve Hand Functions in Stroke Patients Dr. Snehal N. Waghavkar1*, Dr. Suvarna S. Ganvir2

Abstract

Aim of the study: To find out the effectiveness of Mirror Therapy to improve hand functions

in stroke patients. Statistical analysis used: For all studies we calculated the mean difference & the pooled

the standard deviation of the baselines & at next assessment. Total No. of participants were 157 in 6 studies. The age range was 50 to 71.1 yrs with the mean age of 59.18 yrs & the duration of stroke was 5.83 yrs. Results: Six studies were selected, and outcome data were obtained for each study. Each

outcome measure shows statistical significant improvement in favour of Mirror therarapy to improve hand functions in stroke patients. Conclusion: From the present study it was concluded that Mirror Therapy is effective in

improving hand functions in stroke patients. Key-words: stroke, mirror therapy.

Introduction According to WHO stroke is the â&#x20AC;&#x153;acute

According to W.H.O (16 Nov. 2011) in

onset of neurological dysfunction due to

India incidence of stroke was 130/ 100000

abnormality in cerebral circulation with

individuals every year2. The average

resultant

that

annual incidence rate of stroke was 145

corresponds to involvement of focal area

per 100 000 persons per year. According to

of brain lasting more than 24 hrsâ&#x20AC;?.1

Bobath concept there are three stages of

signs

and

symptoms

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Page 40

[Research Report] stroke. Acute stage, subacute stage and

technique11,

chronic stage. Acute stage is prolonged up

programs, Electrical Muscle Stimulation12.

to 0-2 week, subacute stage is up to 2 years and chronic stage is more than 2 years.3

Task

oriented

Mirror therapy is one relatively new type of treatment that has been shown to have a

Eighty-five percent of stroke patients

positive

experience

hemiparesis due to CVA13

upper

extremity

motor

exercises

impact

patients

with

Treatment

dysfunction4. They do not precisely know

using mirror therapy consists of the client

what their motor ability is and tend to have

placing their affected hand into a mirror

a negative perception about it. Such

box,

perceptions discourage their willingness to

movements. The client must keep his or

actively

rehabilitation

her eyes focused on the mirror box, so that

treatment5. Therefore, in order to induce

the brain may be tricked into thinking that

them to actively6.Cognitive intervention

the reflection of the unaffected hand is

methods

therapy

actually the affected hand moving in a

proposed by Altschuler et al., cognitive

normal fashion. The use of mirror therapy

exercise therapy7. Among these, mirror

with individuals who have experienced a

therapy provides the visual illusion of a

CVA is based on the idea that patients can

functional paretic limb by using the mirror

use visual feedback from movements

reflection of the non-paretic limb, thereby

caused by normal functioning muscles to

improving the function of the paretic

retrain muscles affected by the CVA14.

limb8. It is simple to apply, cost-effective,

Ramachandran

and can improve a

patient’s upper

that paralysis following stroke might have

extremity function through his or her

a ‘learned’ component, which could

voluntary participation9. Mirror therapy is

possibly be ‘unlearned’ by means of the

a treatment method focusing on movement

mirror illusion.15 Others suggested that

of the non-paretic limb10 participate,

mirror therapy might be a form of visually

cognitive intervention as well as physical

guided motor imagery.16

participate

include

the

mirror

exercise is necessary.

and

performing

bilateral

originally

hand

hypothesised

Motor imagery itself has proven to be

Traditionally the techniques which is used

effective in the rehabilitation of patients

for improving hand function includes

with hemiparesis17 and the mirror induced

proprioceptive neuromuscular facilitation

visual feedback of the imagined movement might further facilitate this. There is

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Page 41

[Research Report] limited research supporting mirror therapy

(MAS), Hand-related functioning (self-

as a successful intervention for improving

care items of the FIM instrument),Wolf

hand

Motor

function

hemiparesis

who

individuals

had

with

experienced

CVA18. This study contributes to the current body of evidence regarding the effectiveness of mirror therapy as an intervention

treating

patients

experiencing hemiparesis after a stroke, particularly for the treatment of hand

Test,

SEMG,

Rhythm,

MFT..Pooled Mean of duration of Stroke in above study was 5.83 yrs.

Results Outcome Measures Chart and results is shown in table 1.

dysfunctions.

Discussion

Subjects & Methods

From the combined results of the study it

We included 6 original articles with Mirror Therapy as one of the intervention for patients with stroke in improving Upper Extremity Functions. The studies were either Randomized controlled trial or experimental

nature

studies

with

participants as patients with stroke were included. We were interested to examine the effect of Mirror Therapy on Hand Functions. Intervention along with mirror therapy included Task Specific Exercise, Conventional Therapy.

Physiotherapy

Outcome

Sham

measures

were

included Action Research Arm Test (ARAT), Fugl-Meyer Assessment (FMA) of

physical

performance,

Voluntary

Control Grading (VCG) Scale,Motricity Index, Functional Independence Measure Score,

Brunnstrom

recovery,

Modified

stages

motor

Ashworth

Scale

is observed that Mirror Therapy is effective in improving Hand functions in patients

with

Stroke.

The

neural

mechanisms underlying the efficacy of MT are not clear. But several mechanisms have been proposed for the effect of MT on motor

recovery

after

stroke.

Ramachandran15 originally hypothesized that paralysis following stroke might have a “learned” component, which could possibly be “unlearned” by means of the mirror illusion16. Within stroke patients, the

sensomotoric

coupling

often

disturbed, which might compromise taskintrinsic feedback17. Therefore, to recover motor function stroke patients may be more dependent on augmented feedback18. This

augmented

feedback

might

delivered in the form of visual feedback through MT19. In line with this notion,

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Page 42

[Research Report] Stevens and Stoykov16 have suggested that

awareness of the self and spatial attention.

in MT, the mirror creates visual feedback

The authors concluded that, by increasing

of successful performance of the imagined

awareness of the affected limb, the mirror

action of the impaired limb. Another

illusion might reduce learnt non-use.

possible working mechanism behind MT is the activation of mirror neuron system triggered by the observation of mirror illusion

17-19

. Mirror neurons discharge not

only during action execution but also during

action

observation17,

The

discharge of these neurons is associated with object-oriented hand actions such as grasping,

holding,

manipulating

20, 21

tearing,

and

. Such neurons are found

in the frontal lobes as well as in the parietal lobes20. These areas are rich in motor command neurons each of which fires to orchestrate a sequence of muscle twitches

produce

simple

skilled

movements22. These cortical areas are supposed to be activated by MT which suggests that they might be involved in the efficacy of MT in stroke 29,30. The effect of mirror visual illusions on brain activity has also been investigated. Garry et al.31 performed TMS during mirror illusions in healthy subjects and found increased excitability of primary motor cortex (M1) of the hand behind the mirror. However Michielsen et al.32 reported that mirror illusion caused increased activity in the precuneus and the posterior cingulate cortex, these areas are associated with

Alschuler et al.33 proposed that the mirror reflection of the good moving arm, which looks like the affected arm moving correctly, substitutes the often decreased or void proprioceptive input, thus helping recruit the premotor cortex and improve motor

rehabilitation

through

interaction with the premotor cortex. In addition, Liepert et al.34 reported that the primary motor cortex was excited by hand movements and thus the ipsilateral MI excitability

known

increase

contraction strength as voluntary unilateral arm/hand movements induced excitability changes in both the contralateral and ipsilateral primary motor cortex (M1).35 Motor

imagery

itself,

the

mental

performance of a movement without overt execution of this movement, has proven to be

potentially

rehabilitation

beneficial

the

hemiparesis. Mirror

neurons are bimodal visuomotor neurons that are active during action observation, mental stimulation (imagery), and action execution. For example, it has been shown that passive observation of an action facilitates M1 excitability of the muscles used

that

specific

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

action.37Mirror

Page 43

[Research Report] neurons are now generally understood to

Carson42,43 explored the potential for

be the system underlying the learning of

bilateral interactions to occur in various

new skills by visual inspection of the skill.

brain regions, giving rise to functional

In 3 patients with brachial plexus avulsion,

improvements in the control of the paretic

Giraux and Sirigu38used a virtual reality

limb when movements are performed in a

system

pre-recorded

bimanual context. He suggested that when

movements of a hand to create the illusion

the nonparetic limb engaged during motor

of normal hand movement. During an 8-

training, crossed facilitatory drive from the

week training program, patients were

intact

asked to try to match the movement of the

increased excitability in the homologous

unseen involved hand with the displayed

motor pathways of the paretic limb,

hand movements. After the training period

facilitating recovery of function.

an increased activity in M1 corresponding

Conclusion

displaying

with the affected limb was found using functional magnetic resonance imaging. In addition

previously

reported

“observation with intent to initiate”39or “stimulation

through

simulation”40

mechanisms based on increased visual or mental imagery feedback, another possible mechanism for the effectiveness of the

move the paretic hand as much as they could while moving the nonparetic hand

that Mirror Therapy is effective in improving

2. 3.

al41investigated

bilateral arm training and reported that

compared with unilateral training, bilateral training intervention was more effective in facilitating upper-limb motor function in chronic stroke patients. In a recent review

functions

stroke

References

bilateral training approach. Summers et effectiveness

hand

patients.

and watching the image in the mirror in a the

give rise to

From the present study it was concluded

mirror therapy might be bilateral arm training. In this study we asked patients to

hemisphere will

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[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

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Magill RA: Motor learning and Control: Concept and application (7th ed). New Work: McGraw-Hill, 2003, pp 247–304. Altschuler EL, Wisdom SB, Stone L, et al.: Rehabilitation of hemiparesis after stroke with a mirror. Lancet, 1999, 353: 2035–2036. [Medline][CrossRef] Stevens JA, Stoykov ME: Using motor imagery in the rehabilitation of hemiparesis. Arch Phys Med Rehabil, 2003, 84: 1090–1092. [Medline][CrossRef] Yavuzer G, Sellens R, Sezer F, et al.: Mirror therapy improves hand function in subacute stroke: a randomized controlled trial. Arch Phys Med Rehabil, 2008, 89: 393–398. [Medline] [CrossRef] Sütbeyaz S, Yavuzer G, Sezer N, et al.: Mirror therapy enhances lower extremity motor recovery and motor functioning after stroke: a randomized controlled trial. Arch Phys Med Rehabil, 2007, 88: 555– 559. [Medline] Altschuler, E. L., Wisdom, S. B., Stone, L., Foster, C., Galasko, C., Llewellyn, D., et al. (1999). Rehabilitation of hemiparesis after stroke with a mirror. The Lancet, 353(9169), 2035-2036. Wolf, S. L., LeCraw, D. E., & Barton, L. A. (1989). Comparison of motor copy and targeted biofeedback training techniques for restitution of upper extremity function among patients with neurologic disorders. Physical Therapy, 69(9), 719-735. Ramachandran VS. Phantom limbs, neglect syndromes, repressed memories, and Freudian 404 psychology. International review of neurobiology. 1994;37:291-333 Stevens JA, Stoykov ME. Using motor imagery in the rehabilitation of hemiparesis. Arch Phys 406 Med Rehabil. 2003 Jul;84(7):1090-2. Sharma N, Pomeroy VM, Baron JC. Motor imagery: a backdoor to the motor system after 408 stroke? Stroke. 2006 Jul;37(7):1941-52. Rosen, B., & Lundborg, G. (2005). Training with a mirror in rehabilitation of the hand. Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery, 39, 104-108. Ramachandran VS, Altschuler EL. The use of visual feedback, in particular mirror visual feedback, in restoring brain function. Brain 2009; 132(7):1693-1710. Sterr A, Freivogel S, Schmalohr D. Neurobehavioral aspects of recovery: assessment of the learned nonuse

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phenomenon in hemiparetic adolescents. Archives of Physical Medicine And Rehabilitation 2002; 83(12): 1726-1731 [27] Rothgangel AS, Braun SM, Beurskens AJ, Seitz RJ, Wade DT. The clinical aspects of mirror therapy in rehabilitation: a systematic review of the literature. International Journal of Rehabilitation Research 2011; 34(1):1. Van Dijk H, Jannink MJA, Hermens HJ. Effect of augmented feedback on motor function of the affected upper extremity in rehabilitation patients: a systematic review of randomized controlled trials. J Rehabil Med 2005; 37: 202–211. Moseley GL. Graded motor imagery for pathologic pain: A randomized controlled trial. Neurology 2006; 67(12):2129-2134. Stevens JA, Stoykov MEP. Using motor imagery in the rehabilitation of hemiparesis. Archives of physical medicine and rehabilitation 2003; 84(7):1090-1092. Franceschini M, Agosti M, Cantagallo A, Sale P, Mancuso M, Buccino G. Mirror neurons: action observation treatment as a tool in stroke rehabilitation. European journal of physical and rehabilitation medicine 2010; 46 (4): 517. Dushanova J, Donoghue J: Neurons in Primary Motor Cortex Engaged During Action Observation. Eur J Neurosci 2010; 31(2):386-398. James M. Kilner. More than one pathway to action understanding. Trends Cogn Sci. 2011; 15(8):352-357. Iacoboni M, Mazziotta JC. Mirror Neuron System: Basic Findings and Clinical Applications. Ann Neurol 2007; 62:213218. Gallese V, Fadiga L, Fogassi L, Rizzolatti G. Action recognition in the premotor cortex. Brain 1996; 119(2):593-609. Gallese V, Fadiga L, Fogassi L, Rizzolatti G. Action recognition in the premotor cortex. Brain 1996; 119(2):593-609. Filimon F, Nelson JD, Hagler DJ, Sereno MI. Human cortical representations for reaching: mirror neurons for execution, observation, and imagery. Neuroimage 2007; 37:1315–132. Garry MI, Loftus A, Summers JJ. Mirror, mirror on the wall: viewing a mirror reflection of unilateral hand movements facilitates ipsilateral M1 excitability. Experimental brain research 2005; 163(1):118-122. Michielsen ME. Motor recovery and cortical reorganization after mirror therapy

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in chronic stroke patients - conducted a phase II randomized controlled trial. Neurorehabil Neural Repair 2011; 25(3):223-33. Altschuler EL, Wisdom SB, Stone L, Foster C, Galasko D, Llewellyn DM, Ramachandran VS. Rehabilitation of hemiparesis after stroke with a mirror. Lancet 1999;353: 2035-2036 Kimberley TJ, Lewis SM, Auerbach EJ, Dorsey LL, Lojovich JM, Carey JR. Electrical stimulation driving functional improvements and cortical changes in subjects with stroke. Exp Brain Res 2004; 154: 450-460 Liepert J, Dettmers C, Terborg C, Weiller C. Inhibition of ipsilateral motor cortex during phasic generation of low force. Clin Neurophysiol 2001; 112: 114-121 . Sharma N, Pomeroy VM, Baron JC. Motor imagery: a backdoor to the motor system after stroke? Stroke 2006;37:1941 Fadiga L, Craighero L. Electrophysiology of action representation. J Clin Neurophysiol 2004;21:157-69.

39. Giraux P, Sirigu A. Illusory movements of the paralyzed limb restore motor cortex activity. Neuroimage 2003;20(Suppl 1):S107-11. 40. Pomeroy VM, Clark CA, Simon J, et al. The potential for utilizing the â&#x20AC;&#x153;mirror neurone systemâ&#x20AC;? to enhance recovery of the severely affected upper limb early after stroke: a review and hypothesis. Neurorehabil Neural Repair 2005;19:4-13. 41. Johnson-Frey SH. Stimulation through simulation? Motor imagery and functional reorganization in hemiplegic stroke patients. Brain Cogn 2004;55:328-31. 42. Summers JJ, Kagerer FA, Garry MI, Hiraga CY, Loftus A, Cauraugh JH. Bilateral and unilateral movement training on upper limb function in chronic stroke patients: a TMS study. J Neurol Sci 2007;252:76-82.

Table Outcome Measures Action Research Arm Test

No. of Intervention Study A 2

FMA

VCG FIM

1 2

Motricity 1 Index Brunnsrom 1 stages of motor recovery MAS

MMT

Pre 21

Post 25.5

15.90 24.25 4.3 2.75 52 23.7 39.27 Hand

P value B

Pre 22.42

Post 24.66

47.64* 29.58 20.7* 3.34 93.18* 28.9* 76*

21 26.75 5.3 2.92 45.67 21.1 36.83

2.6

3.5*

2.7

HF HE

1.4 0.4 1.2 1.4

Pre 21.69

Post 28.77*

< 0.001

33.67 30.5 11.2 3.25 67.42 22.2 51.58

27 5.3 2.69 -

35.38* 15.3 3.85* -

<0.001 <0.001 <0.001 < 0.001 <0.001 < 0.001 <0.001

2.6

2.7

<0.001

3.7*

2.7

3.0

<0.001

1.3 0.7 2.8* 3.0*

1.7 0.2 1.3 1.8

1.6 0.7 2.4 2.6

0.4 1.2 1.7

0.8 2.5 2.6

0.906

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

<0.05 <0.05

Page 46

[Research Report] Wolf Motor 1 Function test SEMG 1

Mu Rhythm

MFT

Table 1

WF WE

1.2 1.4 1.43

2.8* 3.0* 1.96

1.3 1.8 -

2.3 2.6 -

1.2 1.8 -

2.5 2.8 -

<0.05 <0.05 -

Digit test Wrist test C3 CZ C4

5.25

1.84

4.24

3.78

-0.06 -0.11 -0.08 13.10

-0.11 -0.15 -0.11 14.20

-0.06 -0.10 -0.09 12.40

-0.16* -0.21* -0.18* 17.10*

<0.05 <0.05 <0.05 <0.05

Corresponding Author: Dr. Snehal N. Waghavkar 2nd yr MPTh Neurosciences Ekta Colony, Near Modern Foundry, Kedgaon Devi Road, Ahmednagar- 414005 E-mail – snehalnw22@gmail.com Contact No. 7276520468 Co- Author : Dr. Suvarna S. Ganvir Professor, Neurosciences E- mail – suvarna.ganvir @gmail.com © 2014 PGIP. All rights reserved.

Available online at www.pgip.co.uk/jopsm

Postgraduate Institute of Physiotherapy

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Page 47

[Case Report]

Osgood-Schlatter disease in a nonsporting adolescent Manit Arora1 and Prakash D. Samant2

Abstract Osgood-Schlatter disease is a traction apophysitis of the tibial tubercle commonly seen in adolescents, especially those engaged in sporting activities. We present a case of OsgoodSchlatter disease in a non-sporting adolescent managed non-operatively. Key words: Osgood-Schlatter disease. adolescents. sporting adolescent.

Case Report A 16-year-old adolescent male presented

(Figure 2) of the right knee with soft

to our institution with a 3 month history of

tissue

right knee pain on ambulation. There was

confirming the diagnosis of Osgood-

no history of locking or instability. The

Schlatter

patient denied any sporting activities,

managed conservatively in a long knee

history of trauma or previous knee

brace,

complaints. The patient did give a history

application, quadriceps and hamstring

of long yards of ambulation everyday to

strengthening exercises, non-steroidal anti-

fetch water for his family. Constitutional

inflammatory medications and analgesia

symptoms were absent. On examination,

and

the patient had tenderness to the tibial

symptoms at 3 months follow-up.

tuberosity (Figure 1) and a small effusion

swelling

disease.

reduced

showed

with minimal erythema to the same. There

Discussion

was no limitation of range of motion and

Robert

independently

distal

Radiographs

neurovascular of

the

knees

deficit. revealed

fragmentation of the tibial tuberosity

overlying The

complete

and

same,

patient

walking

Osgood

the

activity,

resolution

Carl

described

this

was ice

Schlatter painful

overuse condition of the tibial tuberosity in 19031.

Osgood-Schlatter

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

disease

Page 48

[Case Report] common in active adolescents, possibly

treatment that includes rest, icing, and

caused by multiple small avulsion fracture

activity modification and rehabilitation

from

quadriceps

exercises. In rare cases, surgical excision

muscles at their insertion into the proximal

of the ossicle and/or free cartilaginous

tibial apophysis2. It can best be described

material

as a traction apophysitis of the tibial

skeletally mature patients who remain

tubercle. The disease is associated with

symptomatic despite a trial of conservative

growth spurts and may be bilateral in up to

treatment3.

contractions

the

30% of cases3. The disease typically runs a self-limiting course and usually complete recovery can be expected with closure of the epiphyseal growth plate. Overall prognosis is good.

onset of pain, swelling and tenderness of tibial

tuberosity,

exacerbated

activities that extend the knee against resistance1. Although

radiography

has

been

the

mainstay of diagnosis, ultrasonography has been proposed as a cheaper alternative able to be performed in the consultation room.

give

good

results

References

Patients typically present with gradual the

may

Weiler R, Ingram M, Wolman R. 10Minute Consultation. Osgood-Schlatter disease. BMJ. 2011;343:d4534. De Lucena GL, dos Santos Gomes C, Guerra RO. Prevalence and associated factors of Osgood-Schlatter syndrome in a population-based sample of Brazilian adolescents. Am J Sports Med. 2011 Feb;39(2):415–20. Gholve PA, Scher DM, Khakharia S, Widmann RF, Green DW. Osgood Schlatter syndrome. Curr Opin Pediatr. 2007 Feb;19(1):44–50. Blankstein A, Cohen I, Heim M, Diamant L, Salai M, Chechick A, et al. Ultrasonography as a diagnostic modality in Osgood-Schlatter disease. A clinical study and review of the literature. Arch Orthop Trauma Surg. 2001 Oct;121(9):536–9.

Ultrasonographic features include pretibial swelling, fragmentation of the ossification center,

insertional

patellar collection

tendon n

the

thickening and

excessive

infrapatellar

the fluid

bursa4.

Radiographic changes include irregularity of the apophysis with separation from the tibial tuberosity in early stages and fragmentation in later stages3. About 90% of patients respond well to non-operative

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Page 49

[Case Report] Figure Legends

Figure 1 – Clinical

photograph of

patient’s knee.

Figure 2 – Anteroposterior and lateral radiographs of the patient’s knees showing fragmentation

the

tibial

tubercle

apophysis of the right knee.

Available online at www.pgip.co.uk/jopsm

Corresponding Author 1 Dr. Manit Arora (MBBS Hons, MS Ortho) Department of Orthopaedics Padmashree 2 Dr. DY Patil Hospital and Research Centre Navi Mumbai, India E: manit_arora@hotmail.com P: +918452846005 © 2014 PGIP. All rights reserved.

Postgraduate Institute of Physiotherapy [Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Page 50

[Case Report]

Role of Injection Therapy in patient with Shoulder Impingement Syndrome: A Case Study U Q Sheikh1 MSc Advancing Physiotherapy*

Abstract Shoulder Impingement Syndrome (SIS) is one of the most commonly used diagnoses for the shoulder pain. It is commonly described as an encroachment of the subacromial tissues as a result of the narrowing of the subacromial space. Various Intrinsic and extrinsic factors are reported in literature to be the causative factor. Repetitive overhead activity appears to be a significant contributing factor to the impingement syndrome as well as simultaneously existing predisposing elements, such as tendinitis or subacromial spurs, collectively contributing to the development of this condition. Early introduction of conservative management is recommended for a beneficial and optimal outcome in patients with impingement syndrome. This case demonstrates an evidence-based review of the role of injection therapy in the clinical treatment and successful outcome of a patient diagnosed with impingement syndrome. Keywords: Case report; Physiotherapeutic; Glenohumeral articulation; Rotator cuff disease; Shoulder impingement syndrome; Supraspinatus tendon

Introduction Shoulder Impingement Syndrome (SIS)

subacromial

also known as painful arc syndrome,

swimmerâ&#x20AC;&#x2122;s shoulder / throwerâ&#x20AC;&#x2122;s shoulder,

impingement

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

syndrome,

Page 51

[Case Report] supraspinatus syndrome1-3 is the most

NSAIDs and specific exercises 17-20,20,21. In

commonly reported shoulder problem seen

this case study injection therapy had been

by Physiotherapists1-3. It is one of the

used to manage patient symptoms and

common causes of disability and absence

outcomes reported after 3 weeks and 7

from work after low back pain and

week follow ups.

represents

the

major

socioeconomic

challenge4,5.

Case presentation Mr X a 69 year old engineer by profession,

right-handed man with a history of right

encroachment of the subacromial tissue

shoulder pain presented at the clinic. Pain

due to the narrowing of subacromial

started when he was doing some hedge

space6.

towards

cutting and had to stop due to intensity of

the pain. Pain described as sharp in nature

scapular

on the anterior aspect of the right shoulder

SIS

commonly

Factors

contributing

pathomechanical impingement dyskinesis,

described

mechanism

ranging muscle

from

imbalance

and

impaired motor control7-10. Conservative

and

occasions

reported

catching

sensation at about 80° of arm abduction.

management

i.e.

Physiotherapy / Injection therapy is the first line of treatment that reported to have

Pain varies in intensity ranging from 8/10 Visual Analogue Scale (VAS) mostly to 6/10 VAS on a good day.

good outcomes in resolving problem in 70-

Mr X had been prescribed NSAIDs and

patients11-14.

Successful

pain medications which he believes helped

management depends on the clinician

him just for a while. He is unable to raise

accurate diagnosis and interpretation of

his right arm up and unable to carry out his

signs and symptoms8. Various diagnostic

daily activities at work. Lifting, driving,

tests are proposed in literature and among

reaching, abduction of the arm above 80°

them Hawkin’s and Neer’s test are the one

and internal rotation of the shoulder joint

with good reliability and validity15,16.

aggravates the pain while rest, hot packs

90%

Injection therapy plays an important role in managing acute patient symptoms. It helps them to overcome pain and return to their normal level of functioning within their

and medications helps his symptoms. There are no reported red flags and yellow flags. Overall, his general health is in good state.

pain free zone in conjunction with

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Page 52

[Case Report] Detailed Objective examination has been

effects are provided. Informed consent

carried out (Appendix A) and initial

(Written / verbal) been gained and any

diagnosis

questions asked by Mr X was addressed.

Shoulder

Impingement

Syndrome has been hypothesised.

A dose of (40mg) 2ml Depomedrone (Methyl Prednisolone acetate) and 3ml of

Management:

1% Lidocaine was administered into

Treatment

Mr X has been given an informed choice regarding

all

conservative

treatment

options i.e. hydrotherapy, electrotherapy,

patientâ&#x20AC;&#x2122;s right shoulder with a lateral approach under comfortable, safe and aseptic technique.

acupuncture, Intra articular corticosteroid

Aftercare/Complications

injections

and

Mr X was advised to avoid repetitive

therapeutic exercises. Mr X preferred to

activities for 24-48 hours and can return to

control his pain and opted for injection

normal activities as dictated by his pain

therapy.

levels.

with

local

anesthetic

Corticosteroid along with local anesthetic plays an important role in managing pain and inflammation which together helps patient symptoms and quality of life.

Information

regarding

post

injection soreness and all the risk of injections / complication leaflets has been provided. Self management home exercise program was also started. No adverse reaction observed and patient walked out

Outcome Measures:

of the clinic after 20 minutes post injection

Short Form SF36 been used to measure

reducing any risk of anaphylactic shock.

any changes in his quality of life (QOL) and been filed initially before treatment and at the end of the treatment. SF36 is valid and reliable scale to measure QOL. VAS is also used to measure patient pain levels before and after the treatment.

Outcome Assessment:

Mr X was reviewed at week 3 and at 7 weeks and showed dramatic improvement in the pain from 8/10 on VAS pre-injection to 0/10 post injection. There was also improvement in his functional activities

Procedure adopted for Intra articular

and all active right shoulder movements

corticosteroid Injection:

are without pain even on over pressure.

Mr X had been informed about the procedure in detail and written information regarding potential benefits, effects / side

Patient filled SF36, showing dramatic improvement in his quality of life. No

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Page 53

[Case Report] tenderness

reported

examination

over

deltoid

physical area

and

orthopaedic tests came negative.

inferior portion of acromion process. During

shoulder

abduction

head

humerus moves superolaterally resulting in compression on rotator cuff tendons

Discussion

especially

supraspinatus

tendon.

This

The concept of Shoulder Impingement

region of tendon is called as critical zone

Syndrome was first coined by Neerâ&#x20AC;&#x2122;s in

which is avascular and has limited ability

1972

cadaveric

of repair from micro trauma. This result in

dissections22. According to him, the rotator

inflammation and oedema which further

cuff impingement

reduce the already narrow supraspinatus

when

impingement

studied

was as result rotator

cuff

tendon

beneath the acromion in forward flexed and

internally

supraspinatus

rotated space

position. which

The

usually

accommodates the passage and excursion of

supraspinatus

tendon

developed

abnormalities thus resulted in narrowing and impingement syndrome. This leads to weakness of rotator cuff muscles as well1,7,23. Although his study was based on his clinical and surgical experience, the concept of impingement and its basis are still in debate in literature and warrants further investigation to find consensus 24.

outlet 1,7,23. As a result of this, shoulder girdle motion pattern have been altered and patient with SIS demonstrate an increase in gleniod rotation angle. Recent studies also showed alteration

scapula-humeral

rhythm,

supraspinatus action and anterior scapular tilting4,6,10,23,25. Therefore, it would be very important to address all these issues while treating patient with SIS. In author experience, repetitive over head activities as well as patient age plays important role in the aetiology of SIS. Research reveals that in third decade of life SIS has higher

One of the reasons for narrowing of the

prevalence1.

space is the anatomical variant of the

presented, the patient job involves over

acromion which in literature implicated as

head repetitive activities and his age

further not helping the situation as well 25.

causative

impingement

factor

for

shoulder

syndrome1,18,25.

Supraspinatus is the most commonly affected muscle as its inserts between the superior aspect of the head of humerus and

In relation to the case

Many treatment modalities have been reported in literature for the conservative management and corticosteroid injection

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Page 54

[Case Report] with local anaesthetics reports promising results

17,26,27

further work is required in using the

It is reported that relief is mainly due to the

anti-inflammatory

properties

corticosteroids but the exact mechanism of pain

relief

understood

17,27

still

not

completely

. This reduces the pain and

promotes the flexibility and restores normal

rhythm27.

scapula-humeral

Theoretically reducing the pressure in subacromial space and providing a good healing environment17. In

corticosteroid injections are reported but

addition,

standardised outcomes and specific patient groups.

had

progressive

improvement in his symptoms after 7 week review and developed good scapulahumeral rhythm. The author feels that employing corticosteroid injection not only helped patient to overcome his pain but also helps him to gain confidence in movement.

References

corticosteroids

have

subacromial

potential side effects ranging from tendon rupture, inhibiting collagen synthesis,

Lewis JS, Green AS, Dekel S. The aetiology of impingement

syndrome.

Physiotherapy 2001;87(9):458-469. 2.

Koehler

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atrophy to articular cartilage and systemic

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Michener LA, Yesilyaprak SSS, Seitz AL, Timmons MK, Walsworth MK. Supraspinatus

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

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[Case Report] tendon and subacromial space parameters

arthroscopicacromioplasty in the treatment of

measured on ultrasonographic imaging in

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[Case Report] A preliminary report. The Journal of Bone & Joint Surgery 1972;54(1):41-50.

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2006.

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cadaveric study of injection accuracy. Journal

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subacromial and glenohumeral injections in

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Corresponding Author 1 Umer Q Sheikh Extended Scope Practitioner Oxleas NHS Foundation Trust,

41. Kang MN, Rizio L, Prybicien M, Middlemas DA,

Blacksin

subacromial

MF.

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corticosteroid

accuracy

injections:

comparison of multiple methods. Journal of

Shoulder and Elbow Surgery 2008;17(1):S61S66. 42. Partington

PF,

Broome

GH.

Diagnostic

injection around the shoulder: hit and miss? A

Available online at www.pgip.co.uk/jopsm

Postgraduate Institute of Physiotherapy

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

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commentaries

narrative

or more authors, list the first 3 authors,

literature reviews do not have specific

followed by ‘’et al’’. Abbreviations for the

mandatory subdivisions or sections.

journals in references must conform to

Acknowledgements:

and

All

contributors

those of the National Library of Medicine

who do not meet the criteria for authorship

Index

as defined above should be listed in an

(http://www.ncbi.nlm.nih.gov/

acknowledgements section. Examples of

References that have CrossRef Digital

those who might be acknowledged include

Object Identifiers (doi) should include

a person who provided purely technical

them at the end of the citation. References

help, writing assistance, or a department

must be verified by the author(s) against

chair that provided only general support.

the

Authors should disclose whether they had

Reference style and punctuation should

any writing assistance and identify the

conform to the examples that follow:

original

Medicus journals).

documents.

entity that paid for this assistance. References: 75 or fewer. References

should be listed in the order of appearance in

the

manuscript,

numerical

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Page 61

[Guidelines for Authors] Journals

Jones MA, Rivett DA. Introduction to

Titles of journals should be abbreviated as

clinical reasoning. In: Jones MA, Rivett

they appear in the MEDLINE Journals

DA, eds. Clinical Reasoning for Manual

Database.

Therapists. Edinburgh, UK: Butterworth

Petty NJ, Bach TM, Cheek L. Accuracy of

Heinemann;

feedback

2004:3-24.

during

training

passive

accessory intervertebral movements. J

Tables: Tables should be formatted in

Manual Manipulative Ther 2001; 9:99-

Word, numbered consecutively, and placed

108.

together. There should be no more than 6

Book

tables and figures (total). Additional tables

Boscheinen-Morrin J, Conolly WB. The

and figures can be posted online only.

Hand: Fundamentals of Therapy. 3rd ed.

Appendixes:

Boston: Butterworth Heinemann; 2001.

numbered consecutively and placed at the

P.26.

very

Internet

appendixes to provide essential material

Australian Institute of Health and Welfare. Chronic diseases and associated risk factors

[document

the

end

Appendixes of

the

should

manuscript.

be Use

not suitable for figures, tables, or text.

Internet].

Canberra: The Institute; 2004 [updated 2005 June 23; cited 2005 Jun 30]. Available from:

Available online at

http://www.aihw.gov.au/cdarf/index.cfm www.pgip.co.uk/jopsm

E-Journal

Evans C, Dunstan H R, Rothkirch T, Roberts T K, Reichelt K L, Cosford R, et al. Altered amino acid excretion in children with autism. Nutr. Neurosci

Postgraduate Institute of Physiotherapy

[Internet]. 2008 [cited 2009 Aug 12]; 11(3):

259-64.

Available

from

http://www.ingentaconnect.com/content/m aney/nns. Book Chapter

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 2][Dec 2014]

Page 62

Welcome to the Postgraduate Institute of Physiotherapy, we are the team of professional physiotherapists working in United Kingdom promoting and uplifting the physiotherapy profession in developing countries particularly in South Asia. Our well trained and qualified physiotherapists conduct postgraduate courses in various countries. The courses ranged from Musculoskeletal Manual Therapy to Sports Physiotherapy. The basic aim is to provide evidenced based way of practice and education to physiotherapy societies of developing nation so that they can uplift the profession and become the contributors to the profession. Date: 00/00/00

Time: 00:00

www.pgip.co.uk

Encouraging Better Education Ob j e ct ive s

Co ur se s:

Provision of education and training in 1. Spinal Examination and physiotherapy to the public at large Enabling patients to relieve or assist in relieving their own suffering/conditions To persons (professionally qualified or not) providing paid or voluntary care to any person in need of physiotherapy Promotion of research and the dissemination to the public at large of the results of research in the field of physiotherapy

Diagnostic Assessment 2. Management of Neck Disorders 3. Neurodynamics and Neuromatrix 4. Lumbar Spine 5. Cervical Spine 6. Treating Cervicogenic Headaches 7. Low back pain and evidence base approach 8. Spinal Manipulation 9. Evidence Based Practise 10. Clinical Reasoning 11. Professionalism, Empowerment and Autonomy 12. Sports Rehabilitation and injuryIPrevention