Journal of Physiotherapy & Sports Medicine

Vol 1 Issue 2 Dec 2012

ISSN: 2226-9541

JOPSM Journal of Physiotherapy and Sports Medicine A Comparative Study of Serum Lipoprotein Levels in Wrestlers, Boxers and Non-athlete Students.

Effect of Vibration in Prevention of Delayed Onset Muscle Soreness: A Recent Update.

Perception of Physical Therapists about Professional Growth & Development in Developing Countries: Example from Pakistan.

Does Acute Static stretching reduce Muscle Power?

Effects of whiplash injury on median nerve mobility: A comparative study.

Journal of Physiotherapy & Sports Medicine (JOPSM) Volume 1, Issue 2, 2012 Editor-in-Chief

Associate Editor

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

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

Regional coordinator

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

Haseeb Ammad, tDPT (PK), BSPT (PK) – Lahore, PK

International Advisory Board 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

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

Shahbaz Iqbal MSc Physiotherapy (USA), tDPT (USA), McKenzie Cert.

This journal subscribes to the principles of the Committee on Publication Ethics

The Journal of Postgraduate Institute of Physiotherapy Visit the journal website at http://www.pgip.co.uk/jopsm

JOPSM Editorial Office | 13/3 New Civil Lines, Sargodha, Pakistan Tel: +92 (423) 2107625 E-mail: info@pgip.co.uk

Journal of Physiotherapy & Sports Medicine (JOPSM) Volume 1, Issue 2, 2012 Table of Content

Editorial.....................................................................................................................................60 A Comparative Study Of Serum Lipoprotein Levels In Wrestlers, Boxers And Non-Athlete Students…………………………………………………………………………………………………………………..................67 Effect of Vibration in Prevention of Delayed Onset Muscle Soreness: A Recent Update…………...75 Perception of Physical Therapists about Professional Growth & Development in developing countries: Example from Pakistan…………………………………………………………………………………………….86 Does Acute Static stretching reduce Muscle Power?...................................................................104 Effects of Whiplash Injury on Median Nerve Mobility: A Comparative Study..............................115 Guidelines for Authors...............................................................................................................116

The Journal of Postgraduate Institute of Physiotherapy Visit the journal website at http://www.pgip.co.uk/jopsm

JOPSM Editorial Office | 13/3 New Civil Lines, Sargodha, Pakistan Tel: +92 (423) 2107625 E-mail: info@pgip.co.uk

Editorial

Clinical Trial Registration in Physiotherapy Journals: Recommendations from the International Society of Physiotherapy Journal Editors Leonardo O.P. Costa, Chung-Wei Christine Lin, Debora Bevilaqua Grossi, Marisa Cota Mancini, Anne K. Swisher, Chad Cook, Dan Vaughn, Mark R. Elkins, Umer Sheikh*, Ann Moore, Gwendolen Jull, Rebecca L. Craik, Christopher G. Maher, Rinaldo Roberto de Jesus Guirro, AmĂŠlia Pasqual Marques, Michele Harms, Dina Brooks, Guy G. Simoneau, John Henry Strupstad

Clinical trial registration involves placing

importantly, however, it tackles two big

the protocol for a clinical trial on a free,

problems in clinical research: selective

publicly

reporting and publication bias.

available

searchable

and

is

Selective reporting involves investigators

considered to be prospective if the protocol

only reporting the most favourable results

is registered before the trial commences

when they publish a trial, instead of

(i.e.,

reporting the results for all the outcomes

before

register.

electronically

the

first

Registration

participant

is

enrolled). Prospective registration has

that

were

measured.

Reporting

several potential advantages. It could help

favourable

outcomes

can

avoid trials being duplicated unnecessarily

misleading appearance of the effect of a

and it could allow people with health

therapy in the published literature. For

problems to identify trials in which they

example,

might

ineffective intervention is tested across

participate.

Perhaps

more

imagine

that

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

a

only

create

a

completely

Page 60

several trials and each trial measures

the apparent effect of an intervention

multiple outcomes. Most outcomes will

across the published data. For example, a

show

the

trial in which the intervention appeared to

intervention. However, occasionally an

be effective may be published, while the

outcome will show significant benefit or

three other trials in which the intervention

harm simply by chance. If the researchers

appeared ineffective or harmful languish in

publish the positive outcomes but not all of

the filing cabinets of the investigators. If a

the non-significant and negative outcomes,

trial is registered but never published,

readers could interpret falsely that the

authors of a systematic review can still

intervention

similar

find the trial on the register and contact the

problem could occur when outcomes are

authors to request the unpublished data for

analysed

inclusion

no

significant

is

at

effect

beneficial.

multiple

of

A

time

points.

in

the

review.

Therefore,

an

prospective registration of clinical trials

intervention improves walking speed at 6

could further limit bias affecting the body

months, but fail to mention that it does not

of evidence that is available in published

improve walking speed at 1, 2, 3, 9, 12 and

physiotherapy trials.

24 months. Prospective registration of

Prospective

Researchers

may

report

that

clinical

trial

registration

1

clinical trials combats this problem in

encourages transparency and may also

several

and

make it more difficult for fraudulent

reviewers can compare the range of

authors to fabricate data. For example,

outcomes reported in a manuscript against

some journals now ask for individual

those listed in the registered protocol,

patient data to be provided routinely for

requesting that any discrepancies be

checking2 or audit data when fraud is

resolved

protocol.

suspected3. Data collection should have

Readers can also compare the outcomes in

occurred during the dates of data collection

the registered protocol against those in the

defined on the registry. Because many

published

outcomes

ways.

by

Journal

following

report,

editors

the

taking

greater

are

measured

and

stored

reassurance when they are consistent.

electronically with date stamps, this would

Publication bias arises when trials with

increase the planning and complexity

positive results are more likely to be

involved in fabricating data, especially if

published than trials with non-significant

the fabricated data are to withstand the

or

selective

scrutiny of an audit. Also, researchers who

reporting, this can also spuriously inflate

obtain unwelcome data from a particular

negative

results.

Like

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 61

subgroup of patients may be tempted to

subject (p.3)6�. Some ethics committees

eliminate it by retrospectively introducing

have made trial registration a condition of

an additional exclusion criterion. If their

ethical approval.

protocol has been prospectively registered,

Although some physiotherapy journals

however, this would be publicly evident to

have

anyone who compared the registered

registration7,8,9, only about 6% of the

protocol and the report of the trial.

randomised trials investigating the effects

also

encouraged

clinical

trial

of physiotherapy interventions published

1. How common is clinical trial

in

2009

had

been

registered

prospectively10. In an attempt to rectify

registration?

The first major register for healthcare trials

this situation, this editorial recommending

Although

prospective registration has been co-

thousands of trials were soon registered,

authored by several members of the

the

International Society of Physiotherapy

was

established

majority

unregistered. registration

in

of In

was

International

19984.

trials

2004,

remained

clinical

endorsed

Committee

by

of

trial

Journal Editors (ISPJE). The remainder of

the

the editorial will: define which trials

Medical

should

be

registered;

their

trials;

researchers

endorsing

registration,

announce tougher policies about clinical

member journals of the ICMJE made

trial registration that are being adopted by

prospective registration compulsory for all

some member journals of the ISPJE; and

clinical trials that commenced participant

identify who can contribute to ensuring

recruitment after 1 July 20054. Many other

that clinical trial registration achieves its

journals

potential benefits.

also

trial

endorsed

clinical

trial

register

how

Journal Editors (ICMJE)4. In addition to clinical

can

explain

registration and the number of registered trials increased rapidly5. Since then, many organisations have added their support for

2. Which trials should be registered?

clinical trial registration. For example, in

Any clinical trial should be prospectively

2008 the World Medical Association

registered before the first participant is

included a new item on the Declaration of

recruited into the study. The World Health

Helsinki stating that “Every clinical trial

Organization defines clinical trials as “any

must be registered in a publicly accessible

research study that prospectively assigns

database before recruitment of the first

human participants or groups of humans to

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 62

one or more health-related interventions to

comparison(s) studied, study hypotheses,

evaluate the effects on health outcomes�11.

primary

and

secondary

outcomes,

eligibility criteria, sample size, blinding,

3. How can I register my trial?

funding, principal investigators and dates

Clinical trial registration should be quick,

of

easy and free of charge. Many clinical trial

completion of the study. It is common for

registries have been established, including

trial registries to review the information

some that focus on a particular disease (eg,

for completeness and clarity, so some

Internet Stroke Center Trials Registry,

editing might be needed. The registry will

www.strokecenter.org/trials)

or

then provide a unique trial registration

geographical region (eg, Pan African

number to the researchers. This number

Clinical Trials Registry, www.pactr.org).

should be included in all reports of the

Researchers often choose to register their

trial’s results as a link to the registered

trials in their country’s national register,

protocol for editors, reviewers and readers.

although this is not compulsory. It is more

Prospective registration can be done any

important

time

that

researchers

choose

a

commencement

before

the

and

first

anticipated

participant

is

registry that elicits and documents all the

recruited. Many researchers wait until

relevant content from the original protocol

immediately before recruitment starts, so

(outlined below) and that has satisfactory

that any late changes to the protocol (such

quality,

as alterations requested by an ethics

validity,

identification,

accessibility,

technical

unique

capacity

and

committee)

do

not

necessitate

an

administration. To assist researchers, the

amendment to the registry entry. Although

World Health Organization maintains a list

not

of registries that meet these criteria

sometimes made after recruitment starts.

(http://www.who.int/ictrp/network/primary

These should be updated on the registered

/en/index.html). Currently 16 registries are

protocol as well. The trial registry will

listed. Among these, researchers could

publicly document what changed and on

choose one that processes applications

what date.

ideal,

protocol

amendments

are

swiftly or that allows communication When

4. ISPJE member journals

registering their protocol, researchers will

introducing mandatory

be asked to provide information such as

prospective registration

descriptions of the intervention(s) and

policies

using

their

native

language.

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 63

The executive of the ISPJE strongly

participant recruitment after 1 January

recommends that member journals adopt a

2009. The following table lists other

policy

member journals and their nominated dates

of

mandatory

prospective

registration for all clinical trials. Several

to

member journals are implementing such

clinical trial registration, as well as the

policies. Physical Therapy has already

trials that this policy applies to (based on

implemented

the commencement date of participant

prospective

a

policy

clinical

of

trial

mandatory registration,

implement

mandatory

prospective

recruitment).

which applies to trials that commenced

ISPJE Journal Dates to Implement Prospective Clinical Trial Registration Name of the Journal Brazilian Journal of Physical Therapy/Revista Brasileira de Fisioterapia Cardiopulmonary Physical Therapy Journal Journal of Manual and Manipulative Therapy Journal of Physiotherapy Journal of Physiotherapy Sports Medicine Manual Therapy

&

Physical Therapy & Research/Fisioterapia e Pesquisa Physiotherapy Physiotherapy Canada The Journal of Orthopaedic & Sports Physical Therapy Tidsskriftet Fysioterapeuten/ Norwegian Journal of Physiotherapy

â€

Mandatory Registration Date* 1 January 2014

Start of Recruitment Date

1 January 2015

1 January 2014

1 January 2014

6 June 2013

1 January 2013

1 January 2006

1 January 2014

1 June 2013

1 January 2014

1 June 2013

1 January 2014

31 December 2013

1 January 2013 1 January 2013 1 January 2013

1 January 2013 1 January 2013 1 January 2013

1 January 2014

1 July 2013

31 December 2013

*The date after which prospective clinical trial registration becomes mandatory. â€

This

policy

applies

to

trials

that

commence

5. Who else can help ensure

participant

recruitment

after

this

date.

that clinical trial registration achieves its

clinical trial registration

potential

achieves its potential

profession can ensure that their colleagues

benefits?

are aware of clinical trial registration and

In addition to the recommendations for researchers and editorial boards outlined above, others can contribute to ensuring

benefits.

Everyone

in

the

its importance. Educators should ensure that

the

research

component

of

physiotherapy training programs explains

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 64

the

importance

of

trial

registration.

Clinicians can also advise or help patients to search trial registers to identify relevant

International Society of Physiotherapy Journal Editors Leonardo O P Costa and Chung-Wei Christine Lin

volunteer. Administrators of clinical trial

Brazilian Journal of Physical Therapy/Revista Brasileira de Fisioterapia

registries that do not meet the WHO

Debora Bevilaqua Grossi and Marisa Cota Mancini

trials

for

which

the

patient

might

criteria can strive to attain this status.

Grant review panels can make funding contingent upon prospective registration for proposed clinical trials. More ethics review

committees

approval

of

can

trials

make

their

contingent

upon

Cardiopulmonary Journal

Physical

Therapy

Anne K Swisher

Journal of Manual and Manipulative Therapy Chad Cook and Dan Vaughn

Journal of Physiotherapy

prospective registration as well. However,

Mark R Elkins

even universal prospective registration

Journal of Physiotherapy & Sports Medicine

may make no difference to selective

Umer Sheikh

reporting and publication bias unless there is an expectation that protocols will be compared to published reports before publication. Therefore, journal editors and peer reviewers must remember to check for

discrepancies

between

submitted

manuscripts and registry entries.

Physiotherapy clinical

trials that are

conducted and reported according to a prespecified protocol are more likely to provide credible information than those

Manual Therapy Ann Moore and Gwendolen Jull

Physical Therapy Rebecca L Craik and Christopher G Maher

Physical Therapy & Research/Fisioterapia e Pesquisa Rinaldo Roberto de Jesus Guirro and AmĂŠlia Pasqual Marques

Physiotherapy Michele Harms

Physiotherapy Canada Dina Brooks

that do not. Prospective clinical trial registration is therefore of great potential

The Journal of Orthopaedic & Sports Physical Therapy

value to the clinicians, consumers and

Guy G Simoneau

researchers who rely upon clinical trial

Tidsskriftet Fysioterapeuten/Norwegian Journal of Physiotherapy

data

and

that

is

why

ISPJE

is

John Henry Strupstad

recommending that members enact a policy for prospective trial registration.

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 65

7. Askie L, Ghersi D, Simes J. Prospective

References 1. Sim I, Chan AW, Gulmezoglu AM, Evans T, Pang T. Clinical trial registration: transparency is the watchword. Lancet. 2006;367:1631-1633.

2. Herbert RD. Researchers should make data freely available. Aust J Physiother. 2008;54:3.

3. Smith J, Godlee F. Investigating allegations of scientific misconduct - Journals can do only so

registration of clinical trials. Aust J Physiother.

2006;52:237-239.

8. Costa LO, Maher CG, Moseley AM, Sherrington C, Herbert RD, Elkins MR. Editorial: endorsement of trial registration and the CONSORT statement by the Revista Brasileira de Fisioterapia. Rev Bras Fisioter. 2010;14:VVI.

much; institutions need to be willing to

9. Harms M. Clinical trial registration. Physiother.

investigate. BMJ. 2005;331:245-246.

4. de Angelis C, Drazen JM, Frizelle FA, et al.

Clinical trial registration: a statement from the International Committee of Medical Journal Editors. N. Engl. J. Med. 2004;351:1250-1251.

5. Laine C, Horton R, DeAngelis CD, et al. Clinical trial registration - Looking back and moving ahead. N. Engl. J. Med. 2007;356:2734-2736.

6. World Medical Association Declaration of Helsinki. Ethical principles for medical research involving human subjects: World Medical

2011;97:181.

10. Pinto RZ, Elkins MR, Moseley AM, et al.

Comparison of registry entries and published reports of randomised trials: an audit of 200 published trials. Phys Ther. Accepted 12/9/2012.

11. World Health Organization. International Clinical Trials Registry Platform (ICTRP) 2012.

Available from http://www.who.int/ictrp/en/ Accessed 09/07/2012.

Association Declaration of Helsinki. 2008:1-5.

Available online at www.pgip.co.uk/jopsm POSTGRADUATE INSTITUTE OF PHYSIOTHERAPY

* Corresponding author. E-mail address: u.sheikh@pgip.co.uk (Umer Sheikh)

Š 2012 PGIP. All rights reserved.

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 66

A Comparative Study of Serum Lipoprotein Levels in Wrestlers, Boxers and Non-Athlete Students Lotfali Bolboli1, Ali Rajabi2, Navid Lotfi3, Mahdi Nohtani2, Arash Abdolmaleki2

Abstract The purpose of this study was to the comparative study of serum lipoprotein levels in wrestlers, boxers and non-athlete students. 30 students of university of Mohaghegh Ardabili participated in this study (10 wrestlers, 10 boxers and 10 non-athlete students, age: 22/3Âą1/04 year, weight: 83/3Âą3/7 kg and height: 173Âą3 cm). 10 ml blood was drawn from antecubital vein, while they were fasted for 12-14 hours. The one way of ANOVA and Tukey's post-hoc tests were used for data analysis. There was significant difference in total cholesterol between non-athlete students and boxers (p<0/05). But, there were no significant differences in total cholesterol between wrestlers and non-athletes student and between wrestlers and boxers (p> 0.05). HDL concentration in both wrestlers and boxers in comparison with non-athlete students was lower, but these differences were not significant. As a result of this study, it is suggested that wrestlers and boxers use aerobic exercises and interval running for increasing their health. But, more research must be done to obtain more comprehensive information about relationship between sport training and lipoproteins levels.

Key words: Cholesterol, Combat sports, Lipoprotein, Triglyceride

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 67

Introduction

Participating in regular physical activity

In recent years, obesity, lack of physical

and exercise training especially endurance

activity

disease

training even as a recreational can decrease

increased in developing countries and even

mortality related to cardiovascular disease

and

coronary

heart

developed countries. Atherosclerosis or

[20, 23, and 4]

.

hardening of the arteries is due to fatty

Tsopanakis et al (1986) investigated the

deposits and also the creation of foam cells

lipoprotein and lipid profiles of elite

in artery walls, particularly by low-density

athletes in Olympic sports. They reported

lipoprotein that can be affected by some

that endurance sports, such as team games

[25,

(football, basketball, volleyball), as well as

factors such as lifestyle and inheritance 3].

short- and long-distance running showed in

favorable HDL and RF values, indicating

atherosclerosis is ratio of two kinds of

that these sports seem to be protective

lipoproteins which carry a large amount of

against atherogenesis with respect to lipid

cholesterol in the body. Low density

profiles 34.

lipoprotein (LDL) is risk factor and cause

Cox et al (2003) studied the effects of 16

atherosclerosis,

weeks of energy restriction and vigorous

The

most

important

but

thing

high

density

lipoprotein (HDL) prevents expansion of

exercise

layers that create atherosclerosis and is a

composition. They concluded that in

protective factor for blood vessels [22].

sedentary free-living overweight men, 16

Risk factors for cardiovascular disease can

weeks of energy restriction, but not

be influenced by multiplex factors such as

vigorous intensity exercise, results in

smoke, diabetes, lack of physical activity,

substantial reductions in body mass, LBM,

age, gender, high blood pressure, high

and FM. Furthermore, vigorous intensity

cholesterol level and high low density

exercise when combined with energy

[18]

on

body

mass

and

body

. Exercise training

restriction did not modify or enhance the

could affect total cholesterol concentration

changes in body fat distribution or body

and its distribution in high density and low

composition seen with energy restriction

density lipoproteins in long period of time.

alone [10].

Total cholesterol levels are lower in

Durstine et al (2001) studied the blood

persons with high aerobic fitness and

lipid

endurance

exercise.

lipoprotein level

athletes

aerobic fitness [22].

compared

to

low

and

lipoprotein They

reported

adaptations that

to

weekly

exercise caloric expenditures that meet or exceed the higher end of this range are

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 68

more likely to produce the desired lipid

30 students of university of Mohaghegh

changes and physical activity at moderate

Ardabili participated in this study (10

intensities, is reasonable and attainable for

wrestlers, 10 boxers and 10 non-athlete

most individuals [13].

students). They all had at least 3 years

Aellen et al (2008) studied the effects of

training experience. All Subjects were

anaerobic

on

informed of the between two conditions in

lipoprotein concentrations in 45 healthy

potential risks and gave their written

untrained men. They reported that training

informed consent to participate in this

above the anaerobic threshold has no or

study, which was consistent with the

even negative effects on blood lipoprotein

human subject policy of the University of

profiles and beneficial adaptations in

Mohaghegh ardabili.

and

aerobic

training

lipoprotein profile must be achieved with moderate training intensities below the anaerobic threshold [1].

Blood samples measurement

and

variables

10 ml blood was drawn from antecubital

Sady et al (1988) studied the Elevated

vein, while they were fasted for 12-14

high-density lipoprotein cholesterol in

hours. In order to prevent the effects of

endurance athletes and they reported that

exercise sessions on variables, subjects

the low TG levels in endurance athletes

ordered to avoid any of sport activity 3

result at least in part from increased TG

days before sampling. Blood samples

removal and that the elevated HDL

centrifuged for 20 minutes immediately

concentrations of endurance athletes are

after sampling, and then separated serum

related to enhanced fat clearance

[30]

.

and triglyceride total cholesterol, LDL and

The information regarding lipoprotein

HDH

levels of athletes of anaerobic sports is

(Rhoche kit, made in Germany).

measured

by

enzyme

method

limited. Also, due to the intensive nature of boxing and wrestling sports, lipoprotein

Statistical methods

levels may rise in these athletes and may

All descriptive data are expressed as means

have health risks for these athletes.

Âą SD. The one way of ANOVA and

Therefore, the purpose of this study was to

Tukey's post-hoc tests were used for data

the comparative study of serum lipoprotein

analysis. Statistical analysis was conducted

levels in wrestlers, boxers and non-athlete

using SPSS 16.0 for Windows.

students.

Materials and Methods

Results

Subjects

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 69

Subjectsâ&#x20AC;&#x2122; data and body mass index are

positive or negative impact on lipoprotein

shown in Table 1. The lipoproteins

and fat levels [15, 17, and 34].

measures of subjects are presented in Table

Research

2.

lipoproteins and fat levels by changing the

The

results

assessed

diet showed that these changes in a low

concentration is significantly lower in

calorie or very low calorie can decrease

boxers in comparison with wrestlers and

triglyceride, total cholesterol and HDL

non-athlete students (p<0.01). Also, there

levels

were

in

ergogenic aid supplementations which

triglyceride concentration between non-

used widespread by athletes in all fields

athlete and wrestlers groups.

can act as an interfering factor [6 and 38].

There was significant difference in total

Some studies showed that susceptibility to

cholesterol between non-athlete students

atherosclerosis and cardiovascular diseases

and boxers (p<0/05). But, there were no

increase

significant differences in total cholesterol

different types of aerobic training methods

between wrestlers and non-athletes student

with different intensity, volume, time and

and between wrestlers and boxers (p>

frequency can led to lipoprotein and fat

0.05). HDL concentration in both wrestlers

metabolism [37, 27, 12, 11 and 3].

and boxers in comparison with non-athlete

Cross-sectional

students was lower, but these differences

compared

were not significant.

endurance athletes such as endurance

significant

that

which

triglyceride

no

showed

studies

differences

[38, 37, 26, and 30].

in

this

condition.

studies

with

Consumption of

Using

showed

non-athlete

that

people,

Runners and soccer players have lower

Discussion

triglyceride concentration. On the other

The results of our study showed that

hand, strength athletes such as power

triglyceride, total cholesterol and HDL are

lifting athletes that usually have anaerobic

lower in boxers. Lower levels of HDL,

training and non-athletes people had the

triglyceride and total cholesterol show that

same

the factor effectiveness of atherosclerosis

concentration of HDL in wrestlers in

and coronary disease is not only related to

comparison with boxers and control group

the triglyceride and total cholesterol levels

may be due to training feature and

and other factors can be affected it.

especially devoted time and distance for

Studies

indicated

that

losing

weight

running.

level

But,

of

triglyceride.

some

studies

High

reported

repeatedly along with a lack of essential

positive effects of increased running

nutrients in wrestlers or boxers can have

distant on HDL level [27].

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 70

The result of present study in agreement with other studies shows that lower levels of HDL, total cholesterol and triglyceride in boxer are not due to The nature of sport and could be due to influence of other factors. This study shows that in some cases and conditions, HDL can be affected independently without serum fats changes [21, 33, 31, and 19]

.

Conclusions As a result of this study, it is suggested that wrestlers and boxers use aerobic exercises and interval running for increasing their health. But, more research must be done to obtain more comprehensive information about relationship between sport training and lipoproteins levels.

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 71

Table 1- Subjects descriptive data and body mass index Variables

Boxers

Wrestlers

Non-athletes

Age (year)

24±3.8

23±3.7

24±2.8

Weight (kg)

73±1.5

85±1.4

72±1.8

Height (cm)

176±2

175±3

175±6

20.73

24.28

20.57

4±1.2

4±1.2

…….

Body mass index(kg/m2) ) Training experience (year)

Table 2- The concentration of lipoproteins in wrestlers, boxers and nonathlete students Variables

Boxers

Wrestlers

Non-athletes

P

112.70±31.25

156.00±32.21

169.23±31.41

P<0.01

Total cholesterol (mg/dl)

145.20±26.41

172.34±22.12

177.25±35.21

P<0.05

LDL (mg/dl)

75.08±21.02

80.58±26.53

122.14±27.07

P<0.01

HDL (mg/dl)

42.39±5.21

41.56±5.98

38.89±5.23

NS

Triglyceride (mg/dl)

concentration

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 72

apparently healthy Korean individuals:

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Anderson KM, Castelli W.P, Levy D. Cholesterol and mortality. Journal of the American Medical Association. 1987; 257(16): 2176-2180.

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Bakogianni MC, et al. Clinical evaluation of plasma high-density lipoprotein subfractions (HDL2, HDL3) in noninsulin-dependent diabetics with coronary artery disease. Journal of Diabetes and its Complications. 2001; 15(5): 265-269.

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Bouassida A and et al. Leptin, its implication in physical exercise and training: a short review. Journal of Sports Science and Medicine. 2006, 5: 172-181.

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Chul Sung K, Ryu S, Reaven G.M. Relationship between obesity and several cardiovascular disease risk factors in

9.

Couillard C, et al. Effects of endurance exercise training on plasma HDL cholesterol levels depend on levels of triglycerides: evidence from men of the Health, Risk Factors, Exercise Training and Genetics (HERITAGE) Family Study.

Arteriosclerosis, thrombosis, and vascular biology. 2001, 21(7): 1226-1232.

10. Cox K.L, et al. The independent and combined effects of 16 weeks of vigorous exercise and energy restriction on body mass and composition in free-living overweight men (mdash) A randomized controlled trial. Metabolism. 2003; 52(1): 107-115.

11. Cullinane E, et al. Acute decrease in serum triglycerides with exercise: is there a threshold for an exercise effect?

Metabolism. 1982; 31(8): 844-847.

12. Dufaux B, Assmann G, Hollmann W. Plasma lipoprotein and physical activity (Review). Int J Sports Med. 1982; 3: 123126.

13. Durstine J.L, et al. Blood lipid and lipoprotein adaptations to exercise: a quantitative analysis. Sports Medicine.

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14. Elliakim A, Nement D.N, Constantini.

Screening blood tests in member of Olympic teams. J Sports Med phys Fitness. 2002; 42: 250-255.

15. Filaire E, et al. Food restriction, performance, psychological state and lipid values in judo athletes. International journal of sports medicine. 2001; 22(6): 454-459.

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16. Gordon D.J, et al. High-density lipoprotein

in subjects with non-insulin dependent

cholesterol and cardiovascular disease.

diabetes mellitus. J Clin Endocrinol

Four prospective American studies.

Metab. 2002; 77(5): 1345-1351.

Circulation. 1989; 79(1): 8-15.

17. Hagan R.D, Smith M.G, Gettman L.R. High density lipoprotein cholesterol in relation to food consumption and running

25. Nammi S, et al. Obesity: an overview on its current perspectives and treatment options. Nutr J. 2004; 3(3): 1-8.

26. Obrrient N.T, Buithieu J, et al. Lipoprotein

distance. Preventive Medicine. 1983;

compositional changes in fasting and

12(2): 287-295.

postprandial stage on a high carbohydrate

18. Immamura H, Teshima K, Miamoto N,

and low fat and high fat diet in subjects

Shirota T. Cicartte smoking, high density

with non-insulin dependent diabetes

lipoprotein cholesterol subfractions and

mellitus. J Clin Endocrinol Metab. 2002;

lecithine:cholesterol acyltransferase in

77(5): 1345-1351.

young men. Metabolism. 2002; 51(10): 1313-1316.

19. Jacques G, Libby P. Lipoprotein Disorders

27. O'Donovan G, et al. Changes in cardiorespiratory fitness and coronary heart disease risk factors following 24 wk

and Cardiovascular Disease. Braunwald's

of moderate-or high-intensity exercise of

Heart Disease: A Textbook of

equal energy cost. Journal of applied

Cardiovascular Medicine, 2008; 8th ed

physiology. 2005; 98(5): 1619-1625.

1077.

20. Kohl I.H.W. Physical activity and

28. Robins S.J, et al. Relation of gemfibrozil treatment and lipid levels with major

cardiovascular disease: evidence for a dose

coronary events. JAMA: the journal of the

response. Medicine & Science in Sports &

American Medical Association. 2001;

Exercise. 2001; 33(6): 472.

285(12): 1585-1591.

21. Kok Kokkinos P.F, Fernhall B. Physical

29. Sady S.P, et al. Elevated high-density

activity and high density lipoprotein

lipoprotein cholesterol in endurance

cholesterol levels: what is the relationship?

athletes is related to enhanced plasma

Sports medicine. 1999; 28(5): 307-314.

triglyceride clearance. Metabolism. 1988;

22. Lange R.A, Lindsey M.L. HDLcholesterol levels and cardiovascular risk:

37(6): 568-572.

30. Sgouraki, E, A. Tsopanakis, et al. Acute

acCETPing the context. European heart

exercise: response of HDL-c, LDL-c

journal. 2008; 29(22): 2708-2709.

lipoproteins and HDL-c subfractions levels

23. Lee I.M, Skerrett P.J. Physical activity and

in selected sport disciplines. Journal of

all-cause mortality: what is the dose-

sports medicine and physical fitness. 2001;

response relation? Medicine & Science in

41(3): 386-391.

Sports & Exercise. 2001; 33(6): S459.

24. Mcobrrient N.T, Buithieu J, et al.

31. Tall A.R. Exercise to Reduce Cardiovascular Risk-How Much Is

Lipoprotein compositional changes in

Enough?" New England Journal of

fasting and postprandial stage on a high

Medicine. 2002; 347(19): 1522-1524.

carbohydrate and low fat and high fat diet

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32. Thomas S.T.R, Aderniran S.B, Iiits P.L, Aquair C.A, Alblers J.J. Effect of interval and continous training on HDL-c apolipoprotein A-1, B and LCAT enzyme activity. Can. J. Appl. Sport. Sci. 2004; 10: 52-59.

33. Thompson P.D, Rader D.J. Does exercise increase HDL cholesterol in those who need it the most? Arteriosclerosis, Thrombosis, and Vascular Biology. 2001; 21(7): 1097-1098.

34. Tsopanakis C, Kotsarellis D, Tsopanakis A.D. Lipoprotein and lipid profiles of elite athletes in Olympic sports. Int J Sports Med, 1986. 1991, 7(6): 316-321.

35. Ullamnd D.C, Hatcher I.F, et al. Will a high carbohydrate, low fat diet lower plasma lipids and lipoproteins without producing hypertriglycedemia?

Arterioscler Thromb. 1991, 11: 10591067.

36. Wang J.S, et al. Role of chronic exercise in decreasing oxidized LDL-potentiated platelet activation by enhancing plateletderived NO release and bioactivity in rats.

Life sciences. 2000; 66(20): 1937-1948.

37. Westman E.C, et al. Effect of 6-month adherence to a very low carbohydrate diet program. The American journal of medicine. 2002; 113(1): 30-36.

38. Williams P.T, Krauss R.M, Wood P.D, et al. Lipoprotein subfractions of runners and sedentary men. Metabolism. 1986; 35(1): 45-52.

39. Williams M.H. Nutrition for health, fitness and sport: 1999; WCB/McGrawHill.

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Available online at www.pgip.co.uk/jopsm POSTGRADUATE INSTITUTE OF PHYSIOTHERAPY

Address for correspondence: Navid Lotfi (Ph.D student), Department of Physical Education,Islamic Azad University, Ghorveh branch, Ghorveh, IRAN (Janbazan Sq, 66619-83435, p.o.Box: 161) E-mail: navid_lotfi2008@yahoo.com, Phone: +989336177443 1: Associated professor, University of Mohaghegh Ardabili, Ardabil, Iran 2: MSc, University of Mohaghegh Ardabili, Ardabil, Iran 3: Ph.D student, Islamic Azad University, Ghorveh Branch, Ghorveh, Iran

Š 2012 PGIP. All rights reserved.

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 76

Effect of Vibration in Prevention of Delayed Onset Muscle Soreness: A Recent Update *Zubia Veqar, ** Shagufta Imtiyaz

Abstract Delayed onset muscle soreness (DOMS) is muscular pain and discomfort experienced approximately 24-72 hours after exercise. DOMS is due to microscopic muscle fiber tears and is more common after unfamiliar high-force muscular work. It is seen predominantly post eccentric exercise. It is commonly seen after the intensity and volume of training are increased, the order of progression in exercise or a new training regime is performed. DOMS is not a disorder or disease; it can be considered as a painful type I muscle strain injury.

DOMS can limit further exercise in the days following an initial training. It is a matter of concern for coaches, athletic trainers, physiotherapist, and other sports medicine personnel concerned with the athletes. Various pre- and post exercise interventions have been investigated with respect to preventing the subsequent symptoms and treating DOMS. Interventions like pharmacological treatments, therapeutic treatments using physical modalities, and interventions using nutritional supplements have been researched. In the aspect of prevention and treatment of DOMS vibration therapy is effective. Vibration therapy helps to synchronization of motor unit activity by preventing sarcoma disruption and also improves muscular strength, power development and kinesthetic awareness. Thus optimal muscle performance prevents the muscle damage, reducing the chances of DOMS. The purpose of this review is to find out the role of Vibration therapy in preventing DOMS. Key words: DOMS, Vibration therapy, prevention of DOMS, physiotherapy.

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 75

Introduction

therapy prior to eccentric exercise is

In day to day life, sports, and training we

effective in prevention and management of

may come across conditions which may

DOMS26.

lead us to do an unaccustomed /unfamiliar activity. This unaccustomed activity may

Delayed onset muscle soreness

cause

(DOMS)

muscular

pain

and

soreness,

decreased limb activity or swelling which

DOMS

is the result of clinical entity namely

unaccustomed high-force muscular work

delayed onset muscle soreness (DOMS).

and occurs chiefly by eccentric exercise

Exercise induces muscle soreness which

such as downhill running plyometrics and

can be of two types- acute or delayed

resistance training

onset. Acute muscle soreness starts during

develops

exercise and may last up to 4-6 hours

especially with an increase of the intensity

before subsiding. Delayed onset muscle

and volume of training, the order of

soreness develops after 8-10 hours with

exercise is changed or a new training

soreness peaking 24-48 hours post exercise

regime

1-4

is

usually

with

6,27

. DOMS often

after

is

associated

resistance

performed7.

training

DOMS

is

. Theodore Hough was the first one to

categorized as a type I muscle strain

give a detailed description of delayed

injury24 and presents with tenderness or

onset muscle soreness (DOMS) in 19025.

stiffness, to palpation and/or movement24.

He suggested that soreness is experienced in the flexor muscle of middle finger 8-10 hours after performing rhythmic exercise.

This was most likely due to some sort of rupture within the muscle.

Numerous theories of DOMS have been proposed in the literature. There are six hypothesis

theories

which

are

predominantly used to explain mechanism of DOMS. These are Lactic Acid Theory,

Vibration therapy may prevent sarcoma

Muscle spasm Theory, Connective Tissue

disruption which is caused by high tension

Damage theory, Muscle Damage Theory,

development during eccentric exercise

Inflammation theory and Enzyme efflux

lead to improve muscle performance and

Theory.

thus prevent DOMS 27. Amir H Bakhtiyari

strength loss, pain, swelling, tenderness or

et al. carried out the study on, â&#x20AC;&#x153;influence

stiffness to palpation, loss of range of

of vibration on delayed onset of muscle

motion,

soreness following eccentric exerciseâ&#x20AC;?, and

production and mobility31. DOMS is

reached the conclusion that vibration

evident as disruption of the normal

Features

of

flexibility,

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

DOMS

decreased

include

force

Page 76

banding patterns (alignment) of skeletal

Vibration therapy

muscle

Vibration is periodic alteration of force,

and

broadening

or

complete

disruption of sarcomere Z lines.

16,18

The

acceleration and displacement over time in

disruption leads to release of CK, which in

form of mechanical oscillation. Vibration

turn contributes to strength deficits.14,17 In

exercise is a forced oscillation, in a

eccentrically exercised muscle edema,

physical sense, in which energy will

resulting from production of prostaglandin

transfer from an actuator (i.e. the vibration

E2, has been observed at 24, 48, and 72

device) to a resonator (i.e. the human

hours.

19

Prostaglandin E2 also sensitizes

body, or parts of it) 47.

the group IV afferent fibers of muscle connective tissue, which are responsible

Among the first known uses of vibration therapy was the one carried out by a

for dull, aching pain19.

French neurologist, Jeanâ&#x20AC;&#x201C;Martin Charcot Various interventions aimed at alleviating

in 188032. He discovered that the patients

DOMS

like

reported improvement and better sleep

nerve

after a horse-driven or railway carriage

stimulation (TENS), ultrasound, and the

ride, which he attributed to the vibration

administration of aspirin ,other anti-

produced inside the carriage. Encouraged

has

been

Transcutaneous

proposed

electrical 9

inflammatory drugs,

11

10

steroids,

12

vitamin

13

by

these

results

he

combined

an

C and other antioxidants . Despite the

electrically vibrated helmet with a chair

volume of work there is little consensus

for treating Parkinsonism patients. This

among practitioners regarding the most

resulted

effective way to prevent the symptom of

discomfort and in getting them better

DOMS or muscle damage.

sleep.

This pain and discomfort can impede

Prof Nasarov

physical training, performance and daily

application of vibration stimulation in

activities. Hence the prevention DOMS is

sports using the principle that when

of great significance of coaches, trainers

vibration is applied to a distal muscle it is

and therapists.25 Although DOMS is

transmitted to more proximal muscles. He

experienced widely, science has not

helped improve athletesâ&#x20AC;&#x2122; performance with

established

consistent

the application of this principle. To

treatment for it. Vibration therapy in this

conduct his experiments, he used a special

regard has proved effective and has

device that generated vibrations at a

opened the doors of further research.

frequency of 23 Hz. Vibration resulted in

a

sound

and

in

reducing

42

the

patientâ&#x20AC;&#x2122;s

is credited with the first

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 77

an increased range of motion for the

disturbed33. Muscle tension increases

concerned joint, which Nasarov attributed

as the discharge increase which is

to a shift in pain threshold. According to

characterized

his hypothesis, the vibration training, apart

frequency or neural to the muscle. It is

from improving flexibility, would also

maximal for isometric and concentric

facilitate

muscle contraction is within 40-50

in

an

improved

blood

circulation42.

by

the

change

in

pulse per second34.

•

Effects of vibration

The initial length stimulatory muscle

of

the

Three aspects may attribute to acute

Vibration affects the initial length of

vibratory stimulation effects; they are

the intrafusal muscle fibers. Johnson et

motor

of

al (1970)29 elicit TVR in biceps brachii

vibratory stimulation and initial length of

muscle in two different muscle lengths.

stimulatory muscle.

When elbow was 60 degrees flexed

•

pool

activation,

frequency

Motor pool activation

A motor pool is defined as a group of motor spinal neurons that innervate the same muscle. The biological result of motor pool organization is in the fact that motor pools with many neurons produce

finer

movements.

On

a

vibration frequency of 40Hz, the motor neuron may become synchronized and may result in more efficient use of the

(longer muscle length), they found that TVR elicited from lengthened biceps brachii requires less time to reach a higher plateau tension. From this they inference it may be caused due to increased sensitivity of the muscle spindle in the lengthened biceps brachii muscle29.

The physiological Effects of vibration are:

force production potential of the muscle group involved •

The frequency stimulation

27,33

•

.

of

Increase in skin temperature28 Mechanisms of elevation of

vibratory

skin

temperature

The frequency response of the TVR

following:

appears to be highly co related among

•

motor

neuron

recruitment

/

•

150Hz,

1:1

synchrony

becomes

Friction between the

Friction between the skin and subcutaneous tissue

1:1 synchrony up to about 100-150Hz. At higher frequency, more then 100-

as

vibrator and skin

de-

recruitment. Motor neuron responds in

are

•

Direct influence of the blood vessels or on the

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 78

•

vascular autonomic

transmission activity in small

innervations

diameter nociceptive fibre thus

Indirect influence by

causing pain relief 19.

release of chemical

•

•

•

mediator (Bradykinins,

Nazarov and Zilinsky (1984)

histamins )

demonstrated

Combination of all the

stretching could increase range

above

of motion in the shoulder of

immunological

that

vibration

male gymnastic32.

Control in inflammation In case of an inflammation

•

Increase in strength Bosco

and

et

al

(1999)36,37

biochemical markers like C-

concluded that the increase in

reactive

leucocytes

power in generation capacity is

concentration, Creatin kinase

due to the neural adaptation by

and histamines increase.

the application of vibrations.

Recent study by Broadbant

Bakhtiary et al (2007) conclude

Suzanne et al (2010) concluded

that decrease in strength after

that application of 50 Hz

eccentric

vibration

significantly

prevented by the application of

reduce Interlukin-6 (0.02) and

vibration which may increase

Lymphocyte

the activity of muscle spindle

protein

can

laterally

(0.03)

which

converts

into

and

exercise

hence

can

increase

be

the

macrophages and cause further

background tension of skeletal

disruption of the WBC and

tension26.

RBC.

•

Improvement in flexibility

Increased

neutrophil

recruitment is suggestive of

Vibration Therapy and DOMS

reduced inflammation 17.

Prevention

Decrease in Pain

Vibration therapy may improve muscle

Lundeberg et al concluded that

performance and thus prevent DOMS by

pain relief by the use of

preventing sarcoma disruption which is

vibration

caused by high tension development

is

due

to

the

activation of large diameter

during

fibre

therapy

thereby

inhibiting

eccentric leads

to

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

exercise16. elevation

Vibration of

skin

Page 79

temperature and increased blood flow18.

He found decreased IMVC force (P =

Hakami et al. also concluded through their

0.006), reduced PPT (P = 0.0001) and

research that vibration therapy is effective

significantly increased mean of DOMS

in

preventing

decrease

in

and CK levels in the non-VT group,

contraction

of

compared to the VT group (P = 0.001)26.

quadriceps muscles (P < 0.05) and in

Vibration provide stimulation to muscle

pressure pain threshold was indicated (P <

spindle and increases the afferent activities

0.05). A significant decrease in knee joint

of muscle spindles, which may increase

range of motion among Non-VT subjects

background tension and motor unit activity

compared to VT subjects. The mean levels

synchronization

of muscle soreness of VT group (24 hours

muscles44,45.

after eccentric exercise) were significantly

sarcomal

lower than Non-VT group (P < 0.01)35.

excitation窶田ontraction coupling, which can

maximum

DOMS,

voluntary

Exercise training programmes comprising of vibration therapy have been shown to enhance muscle strength, muscle power and

muscle

length36,38,39

and

the

rehabilitation of several musculoskeletal impairments related with disuse atrophy, muscle spasms and low back pain

40,41

.

Thompson and Belanger (2002) also demonstrated that vibration therapy may synchronise

motor

unit

activity

by

increasing muscle spindle activities which may

optimise

neuromuscular

function43Amir H Bakhtiary hypothesises that vibration therapy before eccentric exercise may prevent and control DOMS.

in

This

the

vibrated

turn

prevents

in

disruption

or

damage

to

be a consequence of tension development during optimized

eccentric muscle

exercise46.

Thus

performance

may

control and prevent muscle damage and hence

reduce

DOMS26.

Athletic

performance and training are impeded in case of an injury or soreness. For this reason any intervention that limits the extent of damage or hastens recovery would be of crucial concern to the coach, trainer, or therapist. Vibration therapy is an effective intervention to prevent DOMS and its symptoms. Vibration therapy can be applied over single muscle, group of muscle or whole body to prevent or control DOMS.

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 80

Table: 1 Studies conducted on role of vibration therapy on prevention of DOMS. No.

Investigator

Size

1

Bakhtiary Amir, sfavi farokhi et al 26

50

2

Hakami M, Taghian F, Karimi A35

40

3.

Aminian-Far A, Hadian MR, Olyaei G, Talebian S, Bakhtiary AH48

32

Sample characteris tic non-athletic volunteers

Types of study

Intervention

Outcome measure

Key results

RCT

VT before eccentric exercise 50Hz vibration for 1min in VT group

1. Isometric maximum voluntary contraction force(IMVC ) 2. Pressure pain threshold(P PT) 3. Serum levels of creatinekinase(CK).

female athletes

Experimental

vibration therapy 50Hz for 1 min prior to eccentric exercise

untrained volunteers

RCT

vibratory platform (35 Hz, 5 mm peak to peak) with 100째 of knee flexion for 1min pereccentric exercise.

Maximum voluntary contraction (MVC) pressure pain threshold (PPT) Knee joint's range of motion (flexion and extension) Muscle soreness, thigh circumferenc e, and pressure pain threshold

Decreased IMVC force (P = 0.006), reduced PPT (P = 0.0001) and significantly increased mean of DOMS and CK levels in the non-VT group, compared to the VT group (P = 0.001). decrease in MVC of quadriceps muscles, PPT and knee joint range of motion among Non-VT subjects compared to VT subjects.

IN WBVT group less maximal isometric and isokinetic voluntary strength loss, lower creatine kinase levels, and less pressure pain threshold and muscle soreness, But no effect on thigh circumference .

Conclusion

vibration like reducing muscle soreness,

Vibration therapy may improve muscle

increasing flexibility, increasing blood

performance and thus help to prevent

flow to muscle, controlling inflammation ,

DOMS .The physiological effects of

increase background tension and motor

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 81

unit activity synchronisation may in turn

Proteoglycans. Med Sci Sports Exercise

helps to prevent DOMS. Vibration training

1988; 20: 354-61

previous

to

eccentric

exercise

may

8.

Cheung K, Hume P, Maxwell L. Delayed onset muscle soreness: treatment strategies

facilitate the muscles to build up a

and performance factors. Sports Med.

background

2003; 33(2):145-64

tension

and

optimal

neuromuscular activity to defeat the increased exercised

passive

tension

muscles

during

inside

the

eccentric

activities. However, very few researches have been conducted in this regard and

9.

Denegar RC, Huff BC. High and low frequency TENS in the treatment of induced musculoskeletal pain: a comparison study. Athletic Training 1988;23:235–7.

10. Hasson, S., et al. "Effect of pulsed

hence it is hoped that this paper will set the

ultrasound versus placebo on muscle

stage for further researches to follow.

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20. Fride´n J, Sfakianos P, Hargens A. Muscle

29. Johnston, R.M, bishop B, coffey, G.H.

soreness and intramuscular fluid pressure:

mechanical vibration of skeletal muscle

comparison between eccentric and

.Physical therapy .1970;50(4):499-505.

concentric load.J Appl Physiol.

1986;61(6):2175–2179.

21. Moritani T, Murasmatsu S, Muro M. Activity of motor units during concentric

30. Eklund, G and Hagbath K.E. Normal vibratory reflex in men .Experimental neurology ,1966;16:80-92.

31. McHugh, Malachy P., et al. "Exercise-

and eccentric contractions. Am J Phys

induced muscle damage and potential

Med. 1988;66(6): 338–350.

mechanisms for the repeated bout

22. Lieber RL, Woodburn TM, Fride´n J. Muscle damage induced by eccentric contractions of 25% strain. J Appl Physiol. 1991;70(6):2498–2507.

23. Enoka RM. Eccentric contractions require

effect." Sports Medicine 27.3 (1999): 157170.

32. Albasini, Alfio, Martin Krause, and I. Rembitzki. "Using whole body vibration in physical therapy and sport." Clinical

unique activation strategies by the nervous

practise and treatment exercises. London:

system. J Appl Physiol. 1996;81(6):2339–

Churchill Livingstone Elservier (2010).

2346.

24. Gulick DT, Kimura IF. Delayed onset

33. Martin , B.J, and Park, H.S. analysis of tonic vibration reflex , influence of

muscle soreness: what is it and how do we

vibration variable on motor unit

treat it? J Sport Rehab 1996; 5: 234-43

synchronization and fatigue . Eur Jour Of

25. Szymanski DJ. Recommendations for the avoidance of delayed-onset muscle

Appl physiol 1997;75;504-511.

34. Adrian and Bronk. The Discharge of

soreness. J Strength Cond Res 2001;23:7–

impulses in motor nerve fibers. Part 2, the

13.

frequency of Discharge in reflex and

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voluntary contraction . J.of physiol, 1929;67,119 35. ‫یحک م میمر‬. "The effect of vibration on

42. Nazarov, V., and G. Spivak.

"Development of athlete’s strength abilities by means of biomechanical

preventing the delayed onset muscle

stimulation method." Theory and Practice

soreness in active girls." ‫ هیت زک و طب‬5

of Physical Culture (Moscow) 12 (1987):

(2009): 1-2.

37-39.

36. Bosco C, Colli R, Introini E, Cardinale M,

43. Thompson C, Belanger M. Effects of

Tsarpela O, Madella A, et al. Adaptive

vibration in inline skating on the

responses of human skeletal muscle to

Hoffmann reflex, force, and

vibration exposure. Clin Physiol 1999;

proprioception. Med Sci Sports Exerc

19(2): 183-7.

2002;34:2037–44.

37. Bosco C, Iacovelli M, Tsarpela O,

a.

Ren JC, Fan XL, Song XA, et al.

Cardinale M, Bonifazi M, Tihanyi J, et al.

Influence of 100 Hz sinusoidal

Hormonal responses to whole-body

vibration on muscle spindle

vibration in men. Eur J Appl Physiol

afferents of soleus muscles in

2000; 81(6): 449-54.

suspended situation rat. Space Med Eng 2004;17:340–4.

38. Delecluse, Christophe, M. A. C. H. T. E. L. D. Roelants, and Sabine Verschueren.

b.

Shinohara M, Moritz CT, Pascoe

"Strength increase after whole-body

MA, et al. Prolonged muscle

vibration compared with resistance

vibration increases stretch reflex

training." Medicine and science in sports

amplitude, motor unit discharge

and exercise 35.6 (2003): 1033-1041.

rate, and force fluctuations in a

39. Issurin, V. B., and G. Tenenbaum. "Acute and residual effects of vibratory

hand muscle. J Appl Physiol 2005;99:1835–42.

stimulation on explosive strength in elite

44. McHugh MP, Connolly J, Eston RG, et al.

and amateur athletes." Journal of sports

Exercise induced muscle damage and

sciences 17.3 (1999): 177-182.

potential mechanisms for the repeated

40. Belavý, Daniel L., et al. "Resistive simulated weightbearing exercise with

bout effect. Sports Med 1999;27:158–70 45. Rittweger Jo¨rn. Vibration as an exercise

whole body vibration reduces lumbar

modality: how it may work, and what its

spine deconditioning in bed-

potential might be . Eur J Appl Physiol

rest."Spine 33.5 (2008): E121-131.

(2010) 108:877–904

41. Fontana, Tania L., Carolyn A. Richardson,

46. Aminian-Far A, Hadian MR, Olyaei G,

and Warren R. Stanton. "The effect of

Talebian S, Bakhtiary AH. Whole-body

weightbearing exercise with low

vibration and the prevention and treatment

frequency, whole body vibration on

of delayed-onset muscle soreness. J Athl

lumbosacral proprioception: A pilot study

Train. 2011 Jan-Feb;46(1):43-9.

on normal subjects." Australian Journal of Physiotherapy 51.4 (2005): 259.

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 84

Available online at www.pgip.co.uk/jopsm POSTGRADUATE INSTITUTE OF PHYSIOTHERAPY

* Assistant Professor Centre for Physiotherapy & Rehabilitation Sciences Jamia Millia Islamia New Delhi ** Postgraduate Student (MPT-Sports) Centre for Physiotherapy & Rehabilitation Sciences Jamia Millia Islamia Corresponding Author Zubia Veqar Email: veqar.zubia@gmail.com Address: Centre for Physiotherapy & Rehabilitation Sciences Jamia Millia Islamia, Maulana Mohd Ali Jauhar Marg New Delhi-110025 Ph: +91-9958993486

Š 2012 PGIP. All rights reserved.

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 85

Perception of Physical Therapists about Professional Growth & Development in developing countries: Example from Pakistan Shahzada Junaid Amin*

Abstract The purpose of study was to explore the perception of physiotherapist for the professional growth and development as an individual physiotherapists and the development of physiotherapy as a profession in Pakistan. A secondary aim was to explore the necessary efforts required for professional development in future. Cross-sectional survey was completed in three months. One hundred Physiotherapists participated in the study. Purposive sampling was used and Structured Questionnaire (close ended) was selected as a data collection tool. Necessary measures were taken to ensure the accuracy, reliability and validity of the data collection and analysis. In Pakistan, novice and senior physical therapists are facing problems in their professional practice. Some efforts have done for the professional growth by some associations and individuals which were not very productive. The growth and development is influenced significantly by professional abilities and potential of professionals. Participants reported that they were not satisfied with their earnings and quality of education. The major reasons were the lack of resources, intra and inter coordination among associations, limited opportunity of formal and informal continuous professional development and research activities. Participants stated that the struggle for the regulatory body will be the best achievement to foster advancements in physical therapy practice, [Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 86

research, and education. Mostly the participants were hopeful to foresee their profession developed and standardized system of professional education and practice. Thus future will bring many long years of professional growth and development in the country. The study presents a unique contribution to knowledge relating to evidence about the perception of physiotherapist about their professional development in developing country. It also shows how development process depends on professional abilities and potential of professionals.

The findings from this study will inform the planners and leaders of the profession about the needs of physiotherapist and the undervalued areas in the professional development will be addressed.

Key words: Developing countries, Physiotherapists, Professional growth & development.

Introduction

potential is assessed and goals are agreed upon, using knowledge and skills unique

Physical therapy (also physiotherapy) is a

to physical therapists.1

health

that

provides

The earliest documented origins of actual

to

develop,

physical therapy as a professional group

maintain and restore maximum movement

date back to Per Henrik Ling “Father of

and function throughout life. This includes

Swedish Gymnastics” who founded the

providing

circumstances

Royal Central Institute of Gymnastics

function

(RCIG)

care

treatment

where

to

profession individuals

treatment

movement

in and

are

in

1813

for

massage,

threatened by aging, injury, disease or

manipulation, and exercise. The Swedish

environmental factors. Physical therapy is

word

concerned

and

“sjukgymnast” = “sick-gymnast.” In 1887,

maximizing quality of life and movement

PTs were given official registration by

potential within the spheres of promotion,

Sweden’s National Board of Health and

prevention,

Welfare. 2, 3

habilitation encompasses

with

identifying

treatment/intervention, and

rehabilitation.

physical,

This

psychological,

for

physical

therapist

is

In 1894 four nurses in Great Britain formed

the

Chartered

Society

of

emotional, and social well being. It

Physiotherapy.4

involves the interaction between physical

Physiotherapy at the University of Otago

therapist (PT), patients/clients, other health

in New Zealand in 1913, and the United

professionals, families, care givers, and

States' 1914 Reed College in Portland,

communities in a process where movement

Oregon, which graduated "reconstruction

The

School

of

aides." 5 [Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 87

Physiotherapy in Developing Countries

Physiotherapists are proposed as important for rehabilitation services in developing countries.6 The scope of physical therapy practice rages from an educator to a healer.

Physical therapist has as imperative role in providing rehabilitation services as a member of multidisciplinary team. The physiotherapy is a healthcare professional providing quality to life, not quantity to life.

Physical Therapy (PT) has indeed

become increasingly involved in global health programming. It is at different stages

of

development

in

different

committed to reducing the global burden of disease, it will be important for the profession of PT to more fully define and establish its role in this process. There are differences pertaining to local conditions in each country, and distinctions can also be made between Western and developing nations.

In

Western

development

of

countries,

the

the

physiotherapy

profession spans the last century into the 1800â&#x20AC;&#x2122;s and has been shaped by major events

in

history.10

In

developing

countries, by contrast, the profession is often introduced by Western funded and -

countries; with base similarities and a

run organizations, such as in Cambodia11,

common definition and aim of practice,

Afghanistan12 and Pakistan. There are

there are local variations and traditions affecting its practice and development.7 Physiotherapy practice and education has thus

followed

different

development 8

processes in different countries. This a bit troubling for the profession. Physical therapy does not only provide aid for sports injuries; it aims to both improve

particular

challenges

differ from those in Western countries, such as in Cambodia13.

The research considers various other factors. There is recognition of the personal and professional benefits of working in developing countries for physiotherapists9

and improve quality of death for people

students14.

terminal

illnesses.

Sadly,

developing

physiotherapy in developing nations that

quality of life to get people back to work,

with

to

and

physiotherapy

the

profession of physical therapy is extremely

History of Physiotherapy in Pakistan

underfunded and understaffed in most

In Pakistan, the evolution of Physical

developing countries9. This result in

therapy

patients turning to counterfeit treatment

profession put up with the winding and

options, which most often make the

changing

situation worse. Both developed and

growth. It was not an easy road from

developing countries become increasingly

diploma to Doctor of Physical therapy

dates

paths

back

in

to

1950s.

development

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

The

and

Page 88

(DPT)

program.

of

commenced their practice in the country.

Postgraduate

The other health care professionals started

Medical Centre, Karachi and School of

admiring the role of physical therapy and

physiotherapy, Mayo Hospital, Lahore are

awareness of general public improved

among the oldest physical therapy schools

about the role of physiotherapy.

physiotherapy,

The

school

Jinnah

in Pakistan. The Jinnah Postgraduate Medical Centre is proposed as a pioneer institute in the country. The first school of physiotherapy was established at Jinnah Postgraduate Medical Centre (JPMC) in 1956 by Ministry of Health (MOH), Islamabad

in collaboration with World

Health Organization (WHO). The two-year physiotherapy diploma with minimum entrance requirement of secondary school certificate was started. In 1963 the two years diploma was upgraded to three-year diploma course. In the same year the school

of

got affiliation with

physiotherapy The

University

of

Karachi for three-year B.Sc. Physiotherapy degree program with minimum entrance requirement of Higher Secondary School Certificate.

The

second

School

of

Physiotherapy was established at Mayo Hospital was in 1986, and three years B.Sc physiotherapy program was offered. In 1999, the three-year B.Sc. Physiotherapy course was upgraded to four-year B.Sc. Physiotherapy degree program. decision

was

a

great

The

professional

advancement and they were able to get equivalence

from

the

abroad.15

The

Professional education in Pakistan

The

development

and

delivery

of

education programs varies internationally, but all programmes are expected to meet the minimum requirements set out WCPT guidelines for physical therapy entry level education.16 More than 36 institutes are

offering

different

courses

and

programs throughout the country. The physiotherapy institutions

in

Pakistan

offering entry level graduation programs (BSPT, DPT) and post graduation degree programs (PP-DPT, M.Sc, M.Phil). More than thirty six institutions are offering entry level degree programs. Most of the institutions are offering entry level DPT programs and some offer four-year B.Sc physiotherapy degree programs.

There are six post professional doctor of physical therapy programs, four M.Sc Programs in different specialties, and one M.Phil

program

is

available.

The

"transitional" DPT is the degree conferred upon successful completion of a post professional physical therapist educational program.

The

"transitional"

DPT

is

intended for licensed physical therapists that are already practicing clinicians and

knowledgeable and skilled professionals [Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 89

typically offers a continuing education

rehabilitation

programs

and

research

which includes current topics in physical

centers.17

therapy Practice. Riphah University is also

Many physiotherapists from Pakistan are

offering M.Phil in basic sciences like

working in United State America, Europe,

anatomy, physiology and pharmacology to

Kingdom of Saudi Arabia, United Arab

those professionals who have completed

Emirates, Australia and other developed

the entry level DPT or post professional

countries. Pakistan's estimated population

DPT.

in 2011 is over 187 million making it the world's sixth most-populous country.18 It is

Job opportunities in Pakistan:

roughly estimated that more than 1300

Pakistan is a developing country and almost every profession is under the development phase especially the physical therapy. The pitfall of job opportunities is the ignored and undervalued role of physiotherapists in the health care system by ministry of health. Physiotherapy is not a

priority

when

determining

health

budgets, but a little funding can go a long way. The shortage of physiotherapists only adds to the misusage of treatment.

Physiotherapists can make a huge change in the country by working towards the improvement

of

quality

of

life

in

communities that would not normally have that service. The more active therapy programs available to communities, the less likely it will be for patients to turn to counterfeit practices and treatments that are doing more harm than good. The job opportunities can be created in hospitals, private

clinics,

rehabilitation

centers,

academic institutions, community based

professionals are practicing in various capacities

in

the

country.

The

physiotherapists

are

underprivileged

regarding job opportunities in the country.

The number of fresh graduates will exceed from 4000 till 2020 and will increase the burden more. Few institutions are offering paid and supervised internship for their newly graduates. The jobs announced at the Government level are very limited.

Private sectors have contributed positively to

create

job

opportunities

for

physiotherapist. The lack of awareness about physiotherapy among other health care professionals and public is also a pitfall. A great contribution of Riphah College

of

Rehabilitation

Sciences

(RCRS) is to honor the Physical Therapists with the academic positions. Before Riphah, not a single university of Public as well as in private sector was offering academic positions for Physical therapists.

Since 2009 then other universities also offered the academic positions for Physical

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 90

Therapists.19 Some academic institutions

standards. In developing courtiers like

have well established service structure and

Pakistan, it has to cover many milestones

offering attractive salary packages to their

to compete the international standards. In

employees

and

the beginning the degree was started as a

allowances. The private hospitals are

two years diploma program at JPMC

institutions have contributed a satisfactory

Karachi, and the people having this

role to provide job opportunities to the

diploma were working as technicians in

physical therapists. The pitfall of some

the field deficient of all the basic

private organizations is low staff wedges

knowledge and skills required to treat the

especially in clinical sectors.

patients. Then diploma was converted into

with

other

benefits

a three years program. In 1999, BSc PT Professional growth and development in Pakistan:

upgraded

to

four-year

B.sc physical

Professional Development is the ongoing

therapy program. This was a immense

self-assessment,

and

achievement on the professional ground.

application of knowledge, skills, and

On educational level the improvements are

abilities that meet or exceed contemporary

imperative.

performance continued commensurate

acquisition,

A

number

recent

standards

described

by

developments

competence

and

are

Riphah international university proposed

individualâ&#x20AC;&#x2122;s

as a leading institute in the recent

with

an

have been

of made.

The

and

development. In 2008, first program in

responsibilities within the context of

Doctor of Physical therapy program and

public health, welfare, and safety.20

post professional two-year doctor of

Development is used in three main senses,

physical therapy program (for practicing

â&#x20AC;&#x153;a vision or measure of a desirable society;

Physical Therapists after 16 years of

an historical process of social change;

schooling and the Higher Education

deliberate efforts at improvement by

Commission

development agenciesâ&#x20AC;?21, where the last is

Equivalency of Master/M.Phil to the

the one of relevance for this study. The

program) was started. It is an Honor for

growth and development is influenced

Riphah of being pioneer of the DPT and

significantly by professional abilities and

PP-DPT program. The contribution of

potential of professionals. In developed

Riphah International University Islamabad

countries, the physiotherapy practice is

for

with proper accreditation, protocols and

profession in the country will be always

(physical

therapist)

role

uplifting

remembered

of

the

and

Pakistan

physical

recognized

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

awarded

therapy

by

the

Page 91

Physical Therapy Professionals in golden

period from 2008 to 2012 considered to be

words The M.sc in different specialties is

the golden age in terms of professional

also offered by Riphah international

development.

22

A

mature

entry

level

There has been a national

professional degree was introduced and

upgrading of the physiotherapy curriculum

recognized by the Higher Education

from four-year BSc PT to five-year Doctor

Commission of Pakistan and profession

of Physical therapy. Recently, more than

got autonomous status in the country.23, 24

36 institutes are offering different courses

The

and program throughout the country. More

Association (PPTA) became a member of

than 32 institutes are offering entry level

the World Confederation of Physical

Doctor of Physical therapy programs. The

Therapy (WCPT) in 2011.25

university .

Pakistan

Physical

Therapy

uniform curriculum for entry level DPT

curriculum revision committee (NCRC) of

Role of Professional organizations and Associations in development and growth

higher education commission (HEC) of

The central regularity authority is the

Pakistan. This curriculum is mandatory in

nucleus

all public and private sectors universities.

development.

It was a great achievement in the history of

regulating

physical

unified

accrediate and maintain the professional

curriculum throughout the country. The

standards in the physiotherapy education.

various other issues of the nomenclature of

Some local societies and associations like

DPT and the use of the Dr. Title with DPT

Pakistan

and autonomous practice were addressed

(PPTA) Pakistan physiotherapy society

by

(PPS), and charted society of Physical

program has been designed by the national

the

therapy to

national

have

curriculum

a

revision

of

professional There

is

authority

in

physical

growth no

central

Pakistan

therapy

and

to

association

committee (NCRC) and consensus was

therapy (CSP)

made for the support of the autonomous

professional growth in the country.26

practice and the use of the Dr. Tilt with

Recently,

clarity. All the members of the National

Society has been merged in to the Pakistan

Curriculum Revision Committee (NCRC)

physical therapy association18 (PPTA).

and Higher Education Commission of

These

Pakistan

positively to the professional growth and

(HEC)

curriculum

division

the

are working for the

Pakistan

organizations

but

Physiotherapy

have

their

contributed

played significant role for uplifting the

development,

profession and will always be appreciated

insufficient. These organizations have their

in the history of Physical Therapy. The

own limitations like lack of funds, proper

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

efforts

are

Page 92

leadership, and coordination among the

international health initiatives in a variety

professionals and associations as well.

of settings.

Pakistan

The

Physical

therapy

association

collaboration

between

national

(PPTA) is the most active among all the

organizations is also vital to grow the

exiting organizations and recognized as

profession in the country to cope with the

representative body of physiotherapists

international standards the physiotherapy

with maximum number across the country.

organizations of Pakistan completely lack

PPTA has also got the membership of

of coordination and collaboration between

World Confederation Physical Therapy

them. New talent should be invited to

WCPT in 2011. Moreover, some volunteer

grow new ideas that would help a lot to

professionals are working on the platform

make the field progressed and developed.

of

PPTA

for

the

establishment

of

physiotherapy council in the country.27 The Collaboration organizations

Research, quality, and accreditation of education

between

Research plays essential role to keep pace with the recent development and advances

The World Confederation for Physical

in the professional. The available research

Therapy (WCPT) is the sole international

opportunities are very limited in the

voice for physical therapy, representing

country. Some volunteerâ&#x20AC;&#x2122;s efforts can be

more than 350,000 physical therapists

observed under some organizations and

worldwide

individuals. Recently, the Journal of

through

its

organizations.

28

made

recognize

to

106

member

Some efforts have been

and

Sports

medicine

Pakistani

(JOPSM) is the first ever peer reviewed

physiotherapists internationally. Pakistan

journal in the professional history of

physiotherapy society has been a member

Pakistan. The second effort is International

of World Confederation Physical Therapy

Journal of Rehabilitation sciences (IJRS).29

up to 1998. Now, Pakistan physically

Physical Therapy Research foundation

therapy

full

(PTRF) headed by a panel of specialists

membership of WCPT since 2011. There

and experts, is also contributing and

should be well organized efforts to arrange

sharing

the events and meetings between national

physically therapy association (PPTA) has

and

also

association

international

the

Physiotherapy

has

got

organizations.

So,

Pakistani PTs can actively engage in

research

announced

activities.

to

launch

Pakistan

Pakistan

physical therapy Journal on 8th September 2011.31

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 93

The dilemma of physiotherapy education

newly

is that some non medical institutions are

accreditation of education is still need to

also offering the PT programs without any

be addressed in many institutions.

infrastructure of medical school and no

To cope with international standards is a

affiliation with any teaching hospital as

difficult task in any developing country in

well. Immerse efforts are required to

every aspect of the profession. Most of the

eradicate this practice. Rigorous efforts are

institutions are short of standardized

in demand to develop standards and

teaching facilities. Lack of competent

guidelines to accrediate all PT programs to

academic

ensure in a broad spectrum to achieve

placement of students in specialized

standard in education, the graduates should

clinical setting are major problems of

present

Skills,

many institutions. The professionals lack

Interpersonal Skills and Responsibility,

the necessary skills required for a good

Communication, Information Technology

practitioner in the field. The institutes in

and Numerical Skills, and Psychomotor

the developed countries are offering

Skills . The academically groomed team of

specialized, sub specialized and PhD

professionals will be the cornerstone to

degree programs.

further develop and improve the quality of

Lastly and extremely important is the

PT programs in the country.

continuous

Knowledge,

Cognitive

graduates.

staff,

The

infra

quality

structure

Professional

and

and

development

activities. Through a broad range of Current status and scope of practice in the country:

continuing

professional

development

The start of Doctor of Physical therapy is a

(CPD) activities individuals learn to

new horizon in physical therapy education

maintain, develop and enhance their skills

and practice. Doctor of Physical therapy is

and knowledge. This, in turn, advances

a step towards direct access, autonomous

practice and service delivery. Very limited

and evidence based practice.32 The first

opportunities of CPD are available to the

step towards independent practice has been

professionals. This is also a neglected area

achieved. Physiotherapists are seeking post

especially

graduation degree programs inside the

research and academics training Some

country. Both government and private

CPD can be observed through some

sectors are offering these programs. Before

volunteer efforts relating on clinical topics.

that, the opportunities of post graduation

This area is also required to be addressed

programs were hardly available for the

in professional development.

when

speaking

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

about

the

Page 94

Overall, the strengths of the profession is

About one hundred and fifty physical

strong leadership, a well defined need

therapists of the country were contacted

consistent

physical therapy, volunteer

through e mail and direct personal.

support from strong academicians and

Hundred of them responded and included

clinical educators, and motivated and

in this study. The study was conducted

enthusiastic

professionals

over period of three months. Ethical

consistent

approval was received from the research

should

faculty

and

contribute

improvements physical

and

therapy

to furthering

of

profession

committee.

This

exploratory

study

a

followed an ethnographic research design,

developing level to a point where it is

and data were collected by means of

progressing

individual

towards

the

from

the

continuous

improvement.

structured

interviews

with

professionals.

The data were entered and analyzed using

Aim

SPSS 11.5. The quantitative data was

The primary aim of this study was to

presented in the form of Mean +/- S.D

explore the perception of physiotherapist

along its range. The categorical data was

for

and

presented in the form of frequency tables,

development. A secondary aim was to

percentages and pie charts. Multiple bar

explore the necessary efforts required for

charts were used to present two or more

professional growth in future.

categorical variables. Chi-square test for

the

professional

growth

significance

was

used

to

see

the

Method

association between categorical variables.

Participants were working professionals in

A p-value less than 0.05 were considered

Pakistan. Purposive sampling

significant.

and

Structured

was used

Questionnaire

(close

ended) was selected as a data collection tool. A 14-item Likert-type questionnaire was designed by the author to probe the physiotherapistsâ&#x20AC;&#x2122; attitudes and perceptions about

professional

growth

Cultural issues related to the data collection process:

It is usually considered appropriate to involve both men and women participants in a study, in order to ensure fair

and

representation of the study population.

development. An expert panel consisting

Necessary measures were taken to involve

of internal and external reviewers was

ensuring the participation of both male and

used for construction of the questionnaire.

female physiotherapists in the study.

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 95

Participants

Recruitment

physiotherapists were 25-29 years old, 25 of

participants

involved

purposeful sampling. Inclusion criteria stated that participants must have entry level degree and are in practice with age below than sixty years. A total of 150 potential participants were identified as eligible for inclusion in the study, during the data collection period. The researchers approached all 150 participants to explain the purpose of the study and 100 consented to participate.

physiotherapists were 30-34 years old, 6 physiotherapists were 35-39 were old and one was physiotherapist was 45-49 year old.

In this study 31 females and 69 male physiotherapists participated in which 10 males and 6 females were less than 25 years of age, 36 males and 16 females were between 25-29 year 19 males and 6 females were 30-34 years old, 3 males and 3 females were 35-39 years old and 1 male PT was between 45-49 years of age.

Procedure

After providing informed consent, each

According to the duration of the job 36

participant

a

structured

had 1-2 years of experience, 48 had 3-4

main

researcher.

years of experienced while 16 people had

Interviews lasted between 20 to 30

more than 5 years of experience at time of

minutes.

interview.

interview

completed with

the

There were only 37 PTs (28 males and 9

Results

females)

who

wanted

to

be

physiotherapists by their own choice, 61 Participants

(39 males and 22 females) were in this

In this study, a total of 100 professional Physiotherapist (PT) were interviewed about their opinion regarding their future and

satisfaction

about

professional

development.

4.127

years

with

minimum

and

maximum age 23-46 years i.e. age range was 23 years. The most frequent age (mode) was 25 years.

than

male physiotherapists who did not intend to practice after graduation thatâ&#x20AC;&#x2122;s way they

25

years

profession was insignificant with respect to gender (p-value = 0.302 > 0.05).

There were only 32 (21 males and 11 females) PTs who were satisfied with the professional growth in Pakistan, 67 (47

There were 16 physiotherapists who were less

other professions and there were only two

were in this profession. The choice of the

The average age of respondent was 28.11 Âą

profession because they did not qualify for

of

age,

52

males and 20 females) were not satisfied with the professional growth in Pakistan

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 96

and there was only one male PT who

to those who had more job experience (p-

didn’t know about the satisfaction with

value = 0.000 i.e. < 0.05).

professional growth in Pakistan. The

According to 16 respondents the minimum

satisfaction with the professional growth

salary of PTs to start, should be Rs. 15000

was independent of gender (p-value =

-20000, according to 53 people the salary

0.719 i.e. > 0.05).

should be Rs. 21000-25000 and according

The satisfaction of the professional growth

to 31 respondents the salary should be Rs.

was also statistically insignificant with the

26000-30000.

job experience (p-value =0.152 > 0.05).

Thirty three PTs responded that “Lack of

There were only 35 PTs (28 males and 7

Professionals” is the problem faced by the

females) who were happy with the efforts

PTs in Pakistan, according to 53 lack of

done so for, for professional growth in

opportunities are the main reasons and 14

Pakistan and 65 PTs (41 males and 24

stated that lack of scholarship is the main

females) were not happy about the efforts

difficulty in PT’s profession.

done so for.

46 PTs stated that struggle for the

Among 35 satisfied PTs, 10 had 1-2 years

regulatory body is the best advancement in

of experience, 17 had 3-4 years of

the development of profession, 24 stated

experience and 8 had more than 5 years of

that Post Graduation study is the best

experience. In 65 PTs who were not

advancement

satisfied 26 had 1-2 years of experience,

profession and 30 PTS stated that entry

31 had 3-4 years of experience and 8 had

level

more than 5 years of experience. The

advancement

satisfaction with the efforts done so for

profession.

was independent with job duration (p-

Moreover 40 PTs told that coordination

value = 0.299 i.e. > 0.05)

between

There were only 43 PTs (35 males and 8

development, but according to 36 PTs

females) who were satisfied with their

proper inter disciplinary approach lack in

earning and 57 PTs (34 males and 23

professional development and in view of

females) were not satisfied with their

24 PTs proper supervised training is the

earnings. The male physiotherapist were

lack in professional development.

more satisfied with their earnings as

According to 30 PTs the campaigns which

compared to female (p-value = 0.020 i.e. <

are being done for the betterment of PT

0.05). The physiotherapists who had less

professionals are excellent, in view of 30

job duration were less satisfied as compare

PTs the campaigns which are being done

DPT

PTs

in

the

development

program in

the

lack

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

is

the

best

development

in

of

of

professional

Page 97

for the betterment of PT professional are

job duration, (p-value 0.992 and 0.632

good and 40 people stated that the

respectively)

campaigns which are being done for the betterment of PT professional are poor.

Discussion

According to 53 PTs all the professionals

A self determined questionnaire was

should have get together to share their

designed to conduct a cross sectional

professional experiences once a month,

survey. Variable in the questionnaire are

according to 10 PTs all the PT's should get

based on observations. When the study

together

professional

was launched and approximately one

experiences once in a blue moon and

hundred fifty participants were invited to

according to 37 all the PT's should get

respond

together

physiotherapists

to

to

share

share

their

their

professional

the

questionnaire.

100

responded

the

questionnaire. Most of the participants

experiences once in a six months. that

reported that they were in this profession

international collaboration can grow the

because they did not qualify for other

profession, 16 suggested that research

professions and some of them reported that

development can grow the professions and

they wanted to be physiotherapists by their

according to 28 PTs the evidence based

own

knowledge through audio visual system

physiotherapist were not satisfied with

can grow the profession in Pakistan. The

their salaries and educational status in

opinion regarding growth of the profession

Pakistan. Most of the female participants

due to the international collaboration was

reported that they were not indented to do

significant with respect to job experience

practice after graduation.

(p-value = 0.022 i.e. < 0.05) while it was

Participants reported that they are not

insignificant in males and females opinion

satisfied with the professional growth and

(p-value = 0.249 i.e. > 0.05).

development done up till now in the

Finally, there were 68 people who believed

country. Most of the physiotherapists were

that in future the physiotherapy profession

not happy about the efforts done so far for

will be developed, 26 answered that it will

the professional growth and development

not developed while 6 people believed that

in Pakistan.

the profession will be remained same in

Mostly the novice physical therapists were

future as it is. The perception of the PTâ&#x20AC;&#x2122;s

not satisfied with their earnings and

about

statistically

quality of the education. Participants

insignificant with respect to gender and

reported that the struggle for the regulatory

In

addition

the

56

PTs

future

suggested

was

choice.

Majority

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

of

the

Page 98

body is the best advancement in the

big cities of the country like Lahore,

development of profession. Some other

Islamabad, and Karachi. A further study

stated that entry level DPT program is the

involving a sample of participants from

best advancement in the development of

remote parts of the country might lead to

profession. Moreover participants told that

different findings.

lack of coordination between PTs is a major factor in professional development,

Conclusion

and growth in Pakistan. Participants stated

The current study was unique and entitled

that so far the campaigns which are being

a new body of evidence about the

done for the betterment of PT profession

perception of physiotherapist about their

were not up to the mark. The participants

education, practice and earning. The

suggested that international collaboration

findings from this study will inform the

can grow and develop the profession in the

planners and leaders of the profession

country. The practicing professionals were

about the needs of physiotherapist and the

hopeful that in future about the profession

undervalued areas in the professional

will be developed like other developed

development will be addressed. Physical

countries.

therapy is a growing and developing

Future research should be warranted in

profession

in

order to explore more in depth about the

developing

countries.

perception of physical therapists for

analysis of semi-structured interview data

brilliant future of their profession in

suggested

Pakistan by increasing the sample size.

professional development are the limited

Pakistan

that

like

The

major

other

thematic

obstacles

in

availability of resources, lack of planning,

Limitations

insufficient

Necessary measures were taken to ensure

associations, limited opportunities for

the accuracy, reliability and validity of the

continuous professional development and

data collection and analysis. However, for

research activities. The struggle for the

a number of reasons the findings of this

regulatory

project must be interpreted with caution.

achievement

The

in physical therapy practice, research, and

purposive

applied

in

sampling

this

generalisability

of

procedures

coordination

body to

will

be

foster

among

the

best

advancements

study

decrease

the

education. Some expectations are there to

the

findings.

All

foresee the profession developed and

participants were selected mainly from the

standardized

system

of

professional

education and practice. Thus future will [Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 99

bring many long years of professional

Physiotherapy". Chartered Society of

growth and development in the country.

Physiotherapy. 2011 (Cited 2012 Nov 13).Available from: http://www.csp.org.uk/history

Acknowelgement

5.

Knox, Bruce."History of the School of

This study could not have been prepared

Physiotherapy". School of Physiotherapy

without the generous contribution of the

Centre for Physiotherapy Research. University of Otago. Archived from the original on 2007-

many individuals. Special mention must be

12-24. Retrieved 2008-05-29.

made of Ripahah

Dr Asghar Khan, Director College

of

6.

Rehabilitation

Kay E, Kilonzo C & Harris MJ (1994) Improving rehabilitation services in

Sciences, and Islamabad, who provided

developing nations: the proposed role of

constant and patient advice on a wide

physiotherapists. Physiotherapy.80, 77- 82.

range of technical issues. I thank all of

7.

Higgs J, Refshauge K & Ellis E (2001) Portrait of the physiotherapy profession. Journal of

individuals those involved directly or indirectly in guiding my efforts.

Interprofessional Care. 15, 79 - 89.

8.

Chip chase LS, Galley P, Jull G, McMeeken JM, Refshauge K, Nayler M & Wright A (2006) Looking back at 100 years of

References 1.

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Description of Physical Therapy: [internet].

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London: World Confederation for physical therapy (WCPT): 2011 (Cited 2012 Nov13).Available from: http://www.wcpt.org/description_of_physical_ therapy 2.

A history of physical therapy: [internet].

London. Chiropractors Warwick The charted society of physiotherapy Pakistan: 2010 (Cited 2012 Nov13).Available from: http://www.chiropractorswarwick.co.uk/index. php/about-chiropractors-warwick/a-history-ofneuromusculoskeletal-healthcare/a-history-ofphysiotherapy-physical-therapy/

3.

Sarah Bakewell, "Illustrations from the Wellcome Institute Library: Medical Gymnastics and the Cyriax Collection," Medical History 41 (1997), 487â&#x20AC;&#x201C; 495.

4.

Chartered Society of Physiotherapy [Internet]. "History of the Chartered Society of

9.

K. Cyrana. The undervalued role of physical therapists in developing countries [Internet].Boston: a blog by the international health students of Boston University:2011 (Cited 2012 Nov 05) .Available from:http://internationalhealthstudent.wordpre ss.com/2011/02/09/the-undervalued-role-ofphysical-therapists-in-developing-countriesby-katie-cyrana/

10. Moffat M (2003) The history of physical therapy practice in the United States. Journal of Physical Therapy Education. 17, 15-25.

11. Dunleavy K (2007) Physical therapy education and provision in Cambodia: A framework for choice of systems for development projects.

Disability and Rehabilitation. 29, 903-920.

12. Lammi H (1997) Negotiating a competencebased transfer plan for a physiotherapy training

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

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programme in Afghanistan. Dundee,

from:

University of Dundee.

http://ptrf.net/lectures_detail.php?subid=7

13. Dunleavy K (2007) Physical therapy education

20. Donen, n. (1999). Education: Mandatory

and provision in Cambodia: A framework for

practice self-appraisal: Moving towards

choice of systems for development projects.

outcomes based continuing education. Journal

Disability and Rehabilitation. 29, 903-920.

of evaluation in clinical practice,, 297-303

14. Humphrey K & Carpenter C (2010)

21. Thomas A (2000) Meanings and views on

Experiences of the voluntary physiotherapist

development. In: Allen, T & Thomas, A (Eds.)

role in developing nations. International

Poverty and development into the 21st century.

journal of therapy and rehabilitation. 17, 150-

Oxford, Oxford University Press.

157.

15. A. Khan. The Physical therapy in Pakistan,

22. A. Khan. The First Doctor of Physical Therapy(DPT) and Post-Professional of Doctor

evolution of [internet].Islamabad (IBD):

of Physical Therapy [internet].Islamabad

Physical therapy Research Foundation

(IBD): Physical therapy Research Foundation

(PTRF).2012 (Cited 2012 Dec 03).Available

(PTRF).2012 (Cited 2012 Dec 03).Available

from:

from:

http://ptrf.net/lectures_detail.php?subid=7

http://ptrf.net/lectures_detail.php?subid=7

16. Education: Entry level education. [Internet].

23. A. Khan. A paradigm shift

London: World Confederation for physical

[internet].Islamabad (IBD): Physical therapy

therapy:2012 (Cited 2012 Dec3).Available

Research Foundation (PTRF).2012 (Cited

from http://www.wcpt.org/node/27530

2012 Dec 03).Available from:

17. K. Cyrana. The undervalued role of physical therapists in developing countries

http://ptrf.net/lectures_detail.php?subid=7 24. Minutes of the Final Meeting of HEC National

[Internet].Boston: a blog by the international

Curriculum,Revision Committee on

health students of Boston

Physiotherapy [internet].Islamabad (IBD):

University:2011 (Cited 2012 Nov 05)

Higher education Cimmission, Pakistan.2011

.Available

(Cited 2012 Dec 03).Available

from:http://internationalhealthstudent.wordpre

from:http://www.hec.gov.pk/InsideHEC/Divisi

ss.com/2011/02/09/the-undervalued-role-of-

ons/AECA/CurriculumRevision/Documents/P

physical-therapists-in-developing-countries-

hysiotherapy%20Draft.pdf

by-katie-cyrana/ 18. K. Watkins.Information on other countries

25. Pakistan Physical Therapy Association: [internet]. London: World Confederation for

[internet]. New York (NY): 2007 Palgrave

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Macmillan (Cited 2012 Dec 03).Available

Dec3).Available from:

from:http://hdr.undp.org/en/media/HDR_2007

http://www.wcpt.org/node/24848

2008_EN_Complete.

19. A. Khan. The Physical therapy in Pakistan,

26. Introduction: [internet]. Lahore (LHR) The charted society of physiotherapy Pakistan:

evolution of [internet].Islamabad (IBD):

2010 (Cited 2012 Dec3).Available from:

Physical therapy Research Foundation

http://www.csppak.org/default.asp?ID=1

(PTRF).2012 (Cited 2012 Dec 03).Available

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27. Message from the president [internet].Islamabad (IBD): Pakistan Physical therapy Association.2011 (Cited 2012 Dec 03).Available from: http://www.pakpta.org/ 28. About WCPT: [internet]. London: World Confederation for physical therapy (WCPT): 2011 (Cited 2012 Dec 5).Available from: http://www.wcpt.org/about 29. Introduction: [internet]. Islamabad (IBD): International Journal of Rehabilitation Sciences: 2011 [Cited 2012 Oct 12].Available from: http://www.ijrs.org/ 30. Journal of physiotherpay and Sport Medicine : [internet]. London: Post graduate institute of physiotherapy: 2011 [Cited 2012 Oct 12].Available from: http://http://www.pgip.co.uk/jopsm 31. Latest News [internet].Islamabad (IBD): Pakistan Physical therapy Association.2011 (Cited 2012 Dec 05).Available from: http://www.pakpta.org/ 32. Vision Sentence for Physical Therapy : [internet].New York (NY): American Physical Therapy Association: 2005 (Cited 2012 Oct 10).Available from: http://www.apta.org/Vision2020/

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 102

40

gender

36 30

Frequency

female

Age Group

31.00 / 31.0%

< 25

20 19

25-29

16 10

30-34 10 6

35-39

6

3

0

3

male

male 69.00 / 69.0%

45-49

female

Gender 50

50

47

47 40

30

20

21

20

gender

Frequency

Frequency

40

30

20

21 18

10

11

male

male

8

female

0

gender

10 0

Do

No

Ye

4

no

s

't

Developed

female

remained the same

kn ow

not developed

in future where do you see your profession

are you satisfied with professional growth in Pakistan

40

50 35

34

40

42

Frequency

Frequency

30

23

20

gender

10 8

male

0

female Yes

No

30

20

10

gender

16

14

12

11 5

0 International colleb

male female

Evidence based knowl

research development

Are you satisfied with your earnings

According to you how our profession could grow in Pakistan

Available online at www.pgip.co.uk/jopsm POSTGRADUATE INSTITUTE OF PHYSIOTHERAPY Corresponding Author: *Shahzada Junaid Amin, Lecturer, Department of Physiotherapy, College of Applied Medical Science, University of Hail, Saudi Arabia junaid768@hotmail.com, +966580931017 Š 2012 PGIP. All rights reserved.

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 103

Does Acute Static stretching reduce Muscle Power?

Sameer A. Gohir*, Dr. Francis M. Kozub, Dr. Alan Donnelly.

Abstract Context: Stretching is commonly used as a technique for injury prevention in the training and clinical setting. Recently, stretching in the warm-up has been shown to decrease several muscular performance variables, but the dose-response of this effect is unknown and moreover these stretching bouts are not representative of athletes during warm up procedures, as they are usually time consuming. Our findings may improve the understanding of the neuromuscular responses to stretching and help sportsmen, coaches, physiotherapist and clinicians make decisions for integrating stretching as a part of warm up or rehabilitation treatment plan.

Purpose: The aim of the present study was to examine whether acute static stretching is responsible for losses in isokinetic peak torque production and if it does, than which time of stretching effect muscle peak torque?

Design: Randomized, counterbalanced, within-subjects experimental design.

Setting: A university human project laboratory.

Methods: Twenty (n=20) light to moderate young exercisers, male and female, from University of Limerick community, with an average age of 22.1±3.6 years, height of 175.6±5 cm, and weight of 73.1±9.9 kg, were randomly selected to take part in the study. Prior to the main study, volunteers attended the lab on two occasions to be familiarized with the knee extension protocol on the Con - trex isokinetic system and with the static stretching protocol.

All participants than performed five additional static stretching protocols randomly, in nonconsecutive training session. The stretching protocols were 0, 60,120, 180 and 180 with alternative pattern.

Results: The results of the statistical analysis (P > 0.05) indicated that peak torque remained unchanged following the static stretching for 0-180 sec at 60 & 180° s−1 angular velocities.

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 104

Conclusion: The findings suggest that an athletic stretching (shorter duration) ranging from 0-180 sec does not produce decreases in peak torque. Athletes are not at risk of decreasing isokinetic peak torque if they stretching them before exercise.

Keywords: Static stretching, Isokinetic peak torque, angular velocity, concentric and eccentric muscle work, flexibility.

Introduction

phenomenon and the viscoelastic response

Stretching during warm-up has become a

of human muscles have used unusually

traditional

long (90sec to over 30 min) and possibly

practice

in

preparing 3

for

Although

unrealistic

static stretching has been found to be

individual

effective in producing an acute increase in

practice.

ROM in a joint, 15, 22, 24 recent studies have

static stretching in sporting activities,

shown that static stretching may also result

involving maximal force and power, is

in a significant acute reduction of 5â&#x20AC;&#x201C;30%

considered beneficial, it would seem useful

strength 4, 6, 9, 12, 19, 24 and power production

to determine the effect of duration of

5

stretch on induced decrements of strength.

exercise or athletic events.

of the stretched muscle groups. These

stretching muscle

protocols

groups

2, 9, 12, 13, 21, 24

in

for actual

Since pre-exercise

strength deficits are believed to be the result of decreased contractile forces and 2, 9

Methodology

and persist for

Purpose: The purpose of the present study

These decreases in

was to examine the effects of the duration

muscular performance were also observed

of acute static stretching on isokinetic peak

in complex movements like jumping.5, 16, 23

torque production.

These findings have lead a number of

Participants

researchers to recommend against the

involved assessing pre and post stretching

practice of stretching prior to strength or

isokinetic peak torque of 20 volunteers (13

power activities.5,

However, these

males and 7 females). The participants

recommendations may be questioned, as

were randomly selected from community

the

to

of Limerick University (student or staff)

were

between the ages of 18-28 years with no

neuromuscular drive 9

about 60 min.

stretching

investigate prolonged

12, 19

protocols

force and

decrements

study

other diagnosed history of recent lower

commonly employed stretching routines,

limb injury and other systemic disease

by

affecting the study. They were asked to fill

Some

representative

This

of

athletes.

not

utilized

Selection:

studies

of

this

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 105

out pre-test medical questionnaire in order

subjects experimental design to compare

to assess their general health condition and

the short-term effects of static stretching

individuals who were found in exclusion

on isokinetic peak torque.

criteria were excluded from this study.

The independent variables were static

Written informed participant consent was

stretching (different time), Muscle work

sought and received from all volunteers.

(concentric and eccentric) and velocity (60

Inclusion and Exclusion Criteria: Light

versus 180° s−1). The dependent variable

to moderate exercisers aging 18-28 years,

was isokinetic peak torque.

belonging to University of Limerick

Subjects were randomly assigned to either

community having no issue raised on pre-

the Group A or the Group B. Both groups

exercise questionnaire. Individuals with

completed same regimens of stretching but

disease or recent injury or abnormality

with different time sequence. The time

affecting quadriceps muscle or knee joint,

sequence was also randomized. Both

any systemic disease, any recent lower

groups have control regimen of stretching

limb fracture within past 6 months and any

(0 Sec) too. The sequence of different

tumour of muscle or bone in lower limb

stretching regimen for both groups is given

were set as exclusion criteria.

below.

Experimental

randomized,

Design:

We

used

counterbalanced,

a

within-

Table 1: Sequence of stretching regimens for Group A and Group B

Group A M(n=7) F(n=3) Group B M(n=6) F(n=4)

1st Session

2nd Session

3rd Session

4th Session

5th Session

60 Sec

180 Sec

0 Sec

120 Sec

180 Sec

0 Sec

120 Sec

60 Sec

180 Sec alternative with 1 hour rest

Measurement Procedures: Prior to the

Each volunteer attended the lab on 5

main

the

additional occasions (thus 7 in total) over

laboratory on two occasions to become

3- 4 weeks with a minimum of two clear

familiarised with the right knee extension

days between each laboratory session. At

protocol on the Con - trex isokinetic

each session, volunteers warmed up for 5

system and with the static stretching

minutes on stationary cycle ergometer

protocol.

prior to an initial isokinetic testing session

study,

volunteers

attended

(knee extension at 60 and 180° s−1).

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 106

Volunteers then perfomed a supervised

bring foot near to the buttock and not off

active static stretching regimen for right

to either side while the bent knee will be

quadriceps of varying duration depending

aimed straight down and the foot which is

on their group sequence. Volunteers

bearing the weight, will be pointed

stretched actively for either 0 seconds

straight.

(control), 60, 120 or 180 seconds, with the

Stretching was taught in familiarization

sequence

session and

randomised

between

days.

performed by individuals

Immediately after stretching, a second

themselves undersupervision to make it

isokinetic test for the same muscle was

safer and more realistic in the same way as

done to examine any change in muscle

professional athletes do. Four different

function.

regimens are 0, 60, 120, and 180 sec

At the 5th session, volunteers performed a

stretchings. To make them more safer we

warm up, and then supervised static

asked individuals to divide each regimen

stretching for 180 seconds, followed by

in 30 sec stretching and 5 sec rest period to

measurement of isokinetic peak torque

accomplish it. For instance 30 X 6 to

(representing

stretching

achieve 180 sec regimen with 5 sec rest

measurement), followed by minimum 1

after every 30 sec. Individuals were

hours rest (in order to eliminate the effects

instructed and taught not to overstretch

of static stretching as mentioned by

their thigh muscle.

Fowles et al. 20019and then a second

Each

isokinetic test (representing pre-stretching

(baseline and post stretching) of maximal

measurement). The main purpose of this

voluntary isokinetic knee extensions with

sequence of pre and post stretching

the right leg on each session. Isokinetic

measurement was the elimination of pre-

torque was measured in the seated position

stretching workout on post stretching

on a Con-trex isokinetic dynamometer at

measurement.

60 and 180° sâ&#x2C6;&#x2019;1 angular velocities. The

The stretching done was non-weight

maximum torque limit was set on 300 N.m

bearing as athletes usually perform in

and Sample frequency was 200 Hz.

field. Stretching for right leg let an

In order to have uniform maximum

individual to hold some supporting device

voluntary isokinetic Peak torque, these

with his left hand to improve his/ her

standard principals described by Gandevia

balance. With right hand, he/ she grasp his/

200110 were used in his study.

her dorsal side of foot while flexing knee

Each participant was placed in an upright

joint. He / she then put pressure on it to

seated position and secured to both the

Post

participant

performed

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

2

bouts

Page 107

Con-trex dynamometer and corresponding

60 and eccentric 180) repeated-measures

chair to the manufacturer specifications in

analyses of variance were used to analyze

order to eliminate extraneous movements

isokinetic peak torque. We used SPSS

and to maintain a constant hip joint angle

(version 13.0; SPSS Inc.) and Excel

(90°). We administered all principles of

(version 2003; Microsoft Corp.) for all

positioning as described by Goslin &

statistical analyses. An Alpha level (α) was

Charteris 197911. These principles involve,

set at P≤ 0.05.

a parallel alignment of the limb with the

In each repeated measure ANOVA, the

level arm of the dynamometer, which, in

separated measure was time (5 levels with

turn, was aligned with the anatomical axis

0, 60, 120, 180 and 180 Alternative).

of rotation of the knee joint (Lateral

Additionally the grouping factors (Groups

femoral condyle), and proper stabilization,

& Gender) were employed.

in order to prevent any other movement

For each repeated measure ANOVA,

that could affect the measurements. The

Mauchly’s test of sphericity was used to

resistance pad was placed approximately at

determine that which P value on output

the ankle joint and the subject was

should be used to determine results.

strapped at his thigh, waist and chest. All

Concentric 60 and eccentric 180 values

strength repetitions were performed with

were significant on Mauchly’s test of

the arms folded across the subject’s chest

sphericity, therefore treated with Huynh-

and emergency stopper in their hand.

Feldt test to get P value for test of

In each angular velocity the best peak

significance. While concentric 180 and

torque of the three test contractions

eccentric 60 were not significant on

collected was recorded for data analysis.

Mauchly’s test of sphericity, so their

Torque values from the trials were

values were not treated for any correction.

recorded in N.m. In order to accomplish

All measurements were also corrected for

maximum

weight

values,

each

subject

was

by

dividing

them

on

their

allowed to look at the computer screen for

respective individual weights, and again

visual feedback and received constant

four (concentric 60,

verbal encouragement to perform better on

eccentric 60 and eccentric 180) repeated

each test repetition20. Furthermore, the

measure ANOVA were used to analyze

subjects were instructed to work as hard as

significance in pre and post isokinetic peak

possible in the direction of the movement.

torque after weight correction.

concentric

180,

separate

Four separate (concentric 60, concentric

(concentric 60, concentric 180, eccentric

180, eccentric 60 and eccentric 180) Paired

Statistical

Analysis:

Four

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 108

t-tests (P≤ 0.05) were used to determine

Results

difference between180 sec and alternative

The observed isokinetic peak torques

180 sec stretching regimens on isokinetic

observed at different stretching treatment

peak torque.

for different angular velocities are shown in the table below.

Table 2: The mean ±SD peak isokinetic torque before and after the stretching regimens for the movement velocities 60 and 180° s−1 Angular Velocities

60° s−1 Stretching time Pre

Stretching Protocols

0 sec

Post Pre

60 sec

Post Pre

120 sec

Post Pre

180 sec

Post Pre

Alt.180 sec

Post

180° s−1

Concentric

Eccentric

Concentric

Eccentric

170.5 ±41.5 173.5 ±44.9 166.6 ±49.4 169.4 ±46.6 173.3 ±46 175.8 ±48.2 164.6 ±50.6 166.8 ±43 166.4 ±60.2 177.2 ±49.1

174.8 ±68.8 176.5 ±66.1 168 ±67.6 178.2 ±61.3 172.6 ±63.4 180 ±58.7 171.2 ±70.1 184.8 ±63.8 160 ±66.7 185.5 ±63.4

137.1 ±40.6 141 ±40.4 135.9 ±40.8 141.2 ±47.3 140.6 ±45.7 146.6 ±41.2 137.4 ±33.5 143.7 ±37.8 139.5 ±45.2 144 ±38

161.7 ±59.5 166.3 ±55 166 ±41.4 168.9 ±46.9 160 ±54.3 170.4 ±46.9 169.1 ±60.9 173.3 ±51 151.3 ±38.1 162.3 ±33.4

None of (four) repeated measure ANOVA

randomization

revealed any significant difference in

protocols make any difference on results

isokinetic peak torque. Moreover data was

but there was no effect of these factors on

weight corrected and treated with repeated

isokinetic peak torque.

measure ANOVA again to see whether

Four different paired t-tests (concentric 60,

weight correction could change the results,

concentric 180, eccentric 60 and eccentric

but there were no clear cut effects of

180) revealed no difference between 180

stretching on isokinetic peak torque.

and 180A sec (alternative stretching

We tested measurements for gender effect

pattern,

and than for grouping effect (Group A and

measurement was taken initially and pre

B)

stretching measurement after 1 hour) on

in

order

to

check

whether

in

where

stretching

post

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

treatment

stretching

Page 109

isokinetic peak torque. So, alternative

Most significant feature of our study was

180sec stretching pattern revealed no

inclusion of alternative 180 sec stretching

significant

pattern

effect

in

comparison

to

in

last

session

where

post

ordinary 180sec stretching.

stretching test was done initially in order

In summary our study showed no evidence

to eradicate the effects of muscle fatigue

to suggest that static stretching produced

(due to pre-stretching). But statistical

change in isokinetic peak torque.

treatment showed that there was no significant difference in these patterns.

Discussion of Findings

From this result it became evident that

There was no significant difference in

even by eliminating fatigue (as a result of

isokinetic peak torque before and after

pre-stretching work on post stretching

stretching

statistical

isokinetic peak torque) stretching could

calculations, thus indicating that stretching

not produce any effect on isokinetic peak

has no negative or positive effects on

torque.

muscle peak torque. So, the results of our

There was no effect of gender and

study are in agreement with previous

individual grouping (groups A and B in

17,

revealed

18

by

where they found no

order to randomize sequence of stretching

significant difference in isokinetic peak

treatment) on isokinetic peak torque.

torque after stretching.

Furthermore our data could not prove

Thus 180 sec stretching did not produce

difference

any significant changes in peak torque,

eccentric isokinetic peak torques. In other

although Zakas et al. 200524 showed

words

decrease in peak torque at 300 sec

isokinetic peak torque on both type of

stretching

muscle work.

studies

(study

with

least

static

between

individuals

concentric

produced

and

same

stretching time to produce changes in

Comparing two angular velocities (60 and

isokinetic peak torque). But there is

180° sâ&#x2C6;&#x2019;1) after stretching also revealed no

difference in methodology of this study

significant difference in production of

and our study. They used passive static

isokinetic peak torque. So, our study

stretching while we used active static

results agree with the results of Cramer et

stretching treatment and time of stretching

al. 20046 who described that any change in

also differs having difference of at least

peak torque (if achieved) may not be as

120 seconds.

velocity specific as suggested by Nelson et al. 200119, and any change in muscle isokinetic peak torque is solely related to

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 110

duration of muscle elongation in an acute

is no significant effect of stretching on

bout of stretching.

isokinetic peak torque but these results

An additional reason for the conduction of

cannot deny other positive effects of

the present study was the recommendation

stretching shown by other studies given

made by a number of investigators

5, 12, 19

below.

according to which static stretching should

1- Stretching increases flexibility of

be avoided during warm up prior exercise

muscle. The studies seem pretty clear in its

or competition, as there is a decrease in

support for the efficacy of the single most

strength in muscle groups undergoing

common use of stretching: static stretching

static stretching. These recommendations

to achieve an increase in range of

confuse athletes and coaches as to the

movement. 7, 8

usefulness of static stretching during warm

2- Stretching also decreases muscle related

up. However, the studies reporting strength

injuries. A study of military recruits

losses

static

between 1996 and 1998 who practiced a

stretching have used long durations on a

series of 18 static stretches before and after

single muscle group, which are not

training, compared to a control group who

commonly used by athletes during warm

performed no stretches, demonstrated a

up. It is worth pointing out that a number

significantly lower rate of muscle-related

of studies that observed performance

injuries, but no difference in the rate of

following

of

did not approximate the

bone or joint injuries.1 A 2004 survey of

actual training environment of the athletes,

flexibility training protocols and hamstring

as the static stretching protocols were

strains in professional football clubs in

applied without any aerobic component or

England conducted by Dadebo et al.7 found

sub maximal exercise. Therefore, although

that â&#x20AC;&#x2DC;hamstring stretching was the most

the research design is necessary to isolate

important training factor associated with

the

HSR [hamstring strain rate]â&#x20AC;&#x2122;. The most

decrease

5, 9, 12, 19

protocols

influence

of

stretching,

it

is,

nevertheless, well known that athletes,

common

during warm up, do not solely perform

stretching and the authors concluded that

static stretching, but they incorporate them

HSR went down in inverse relation to the

in

amount of stretching incorporated into

sub

maximal

aerobic

exercise

technique

used

was

static

procedures. So, our study design included

training.

warm-up or sub maximal exercise and

3-

short duration stretching regimens as

rehabilitation is to aid extensibility of the

practised by athletes and showed that there

healing site and return normal muscle

The

aim

of

stretching

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

during

Page 111

length as early as possible. Malliaropoulos

who would be representative of mild to

et al. 200414 assessed the role of stretching

moderately active young persons. It is not

during

II

clear how these results on the isokinetic

hamstring strains and concluded that the

peak torque of the Quadriceps might relate

group â&#x20AC;&#x2DC;which carried out a more intensive

to other high-force muscular performance

stretching programme, was found to have a

in other muscles groups or subject

statistically significant shorter time of

populations. More research is needed on

regaining normal ROM and rehabilitation

the

period.â&#x20AC;&#x2122;

muscular performance in a variety of

rehabilitation

from

grade

dose-response

muscles,

Conclusion

of

stretching

movements,

and

on

subject

populations. static

As this study included static stretching and

lengthening, without causing pain, lasting

studying its acute effects on isokinetic

for 0-180 sec do not

induce loss in

peak torque, so more studies are required

isokinetic peak torque (concentric and

to find out the chronic (long term)

eccentric) production of quadriceps muscle

implication

groups. The results of the present study

performance, and peak torque by utilizing

may prove useful for athletes who are

and practising stretching on daily basis

afraid of practising stretching (due to

over period of 4-6 weeks and than

recent studies showing negative effects of

comparing

stretching) during warm-up procedures,

performance.

prior to exercise or competition, as well as

Also some work is required to find out

for clinicians who incorporate static

effects of stretching on muscle length

stretching in rehabilitation programs. They

when stretched over weeks and this can be

can keep integrating stretching into their

done

regimes of exercises to gain other benefits

relationship curve at baseline and than

including flexibility, decrease rate of

after treatment. Alternative approach can

injuries and strains.

be practised my measuring length of

A

stretching

session

with

by

of

stretching

results

measuring

on

with

length

muscle

baseline

tension

muscle by ultra-sound or successive MRI

Recommendation for Further

over treatment time.

Studies

Another recommendation is to study the

This study was limited to the responses of

effects of stretching on delayed onset of

a convenience sample of young adults,

muscle soreness (DOMS), or fatigue after exercise, as stretching is recommended to

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 112

be practised in cool down period after

Acknowledgments:

exercise by most of the physiotherapists

European Commission, Prof. H. Van

and coaches and they believe that post-

Coppenolle, Ms. Teresa Leahy, Brian Mc

exercise stretching reduces muscle pain,

Grath,

and soreness.

Campbell, All individuals who participated

Eimear

O’

Connel,

Michelle

in this study and administration staff at University of Limerick, IRELAND.

References 1.

8.

(2005) The effectiveness of 3 stretching

Amako M, Oda T, Masuoka K, Yokoi H, et al.

techniques on hamstring flexibility using

(2003) Effect of static stretching on prevention

consistent stretching parameters. J Strength

of injuries for military recruits. Mil Med.,

Cond Res. ,1:27-32

6:442-6 2.

Avela J, Finni T, Liikavainio T, et al. (2004) Neural and mechanical responses of the triceps surae muscle group after one hour repeated fast passive stretches. J Appl Physiol, 96: 25-32

3.

Beaulieu J E. (1981) Developing a stretching program. The Physician Sports Medicine 9:59– 69.

4.

Behm D G, Button D C, Butt J C. (2001) Factors affecting force loss with prolonged stretching. Canadian Journal of Applied Physiology, 26:261–272.

5.

Cornwell A, Nelson A G, Heise G D, et al.

(2001)Acute effects of passive muscle stretching on vertical jump performance.

Journal of Human Movement Studies, 40:307– 324.

6.

Cramer J T, Housh T J, Jonson G O, et al.

(2004) Acute effects of static stretching on peak torque in women. Journal of Strength and Conditioning Research 2:236–241.

7.

Dadebo B, White J, George KP. (2004) A survey of flexibility training protocols and hamstring strains in professional football clubs in England. Br J Sports Med. 4:88-94

Davis D S, Ashby P E, McCale K L, et al.

9.

Fowles, J R, Sale D G, MacDougall J D. (2000) Reduced strength after passive stretch of the human plantarflexors. Journal of Applied Physiology, 89:1179–1188

10. Gandevia S C. (2001) Spinal and Supraspinal Factors in Human Muscle Fatigue, Physiol.

Rev. 81:1725-1789 11. Goslin B R, Charteris J. (1979) Isokinetic dynamometry: Normative data for clinical use in lower extremity (knee) cases. Scandinavian Journal of Rehabilitation Medicine 11:105– 109.

12. Kokkonen J, Nelson A, Cornwell A. (1998) Acute muscle stretching inhibits maximal strength performance. Research Quarterly for Exercise and Sport, 69:411–415.

13. Magnusson S P, Simonsen E B, Aagaard P, et al. (1996) Biomechanical responses to repeated stretches in human hamstring muscle in vivo.

Am J Sports Med , 24:622–628 14. Malliaropoulos N, Papalexandris S, Papalada A, et al. (2004) The role of stretching in rehabilitation of hamstring injuries: 80 athletes follow-up. Med Sci Sports Exerc. , 5:756-9

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15. McNair P, Stanley S. (1996) Effect of passive

20. Porter G K, Kaminski T W, Hatzel B, et al.

stretching and jogging on the series elastic

(2002) An examination of the stretch-

muscle stiffness and range of motion of the

shortening cycle of the dorsiflexors and

ankle joint. British Journal of Sports Medicine,

evertors in uninjured and functionally unstable

4:313–317.

ankles. Journal of Athletic Training, 4:494–

16. McNeal J R, Sands W A. (2003) Acute static stretching reduces lower extremity power in

500.

21. Rosenbaum D, Hennig E (1995) The influence

trained children. Pediatr Exerc Sci, 15:139–

of stretching and warm-up exercises on

145

achilles tendon reflex activity. J Sport Sci ,

17. Mello M L, Gomes P S C. (2002) Efeito agudo de diferentes dura¸c˜oes de alongamento sobre

13:481–490 22. Wiemann K, Hahn K. (1997) Influences of

o pico de torque em membro inferior

strength, stretching and circulatory exercises

dominante: estudo piloto. Annals of XXV

on flexibility parameters of the human

Simp´osio Internacional de Cieˆncias do

hamstrings. International Journal of Sports

Esporte., 10-12

Medicine 18:340–346.

18. Muir I W, Chesworth B M, Vandervoort A A.

23. Young W G, Behm D G. (2003) Effects of

(1999) Effect of a static calf-stretching

running, static stretching and practice jumps on

exercise on the resistive torque during passive

explosive force production and jumping

ankle dorsiflexion in healthy subjects. J Orthop

performance. Journal of Sports Medicine and

Sports Phys Ther , 29:106-15

Physical Fitness 43:21–27.

19. Nelson A G, Guillory I K, Cornwell, et al.

24. Zakas A, Doganis G, (2006) Acute effects of

(2001) Inhibition of maximal voluntary

static stretching duration on isokinetic peak

isokinetic torque production following

torque production of soccer players. Journal of

stretching is velocity-specific. Journal of

Bodywork and Movement Therapies 10:89-95

Strength and Conditioning Research, 2:241– 246.

Available online at www.pgip.co.uk/jopsm POSTGRADUATE INSTITUTE OF PHYSIOTHERAPY Address for correspondence: *Sameer Akram Gohir C/0 Dr. Alan Donnelly Physical Education and Sport Sciences Dept, University of Limerick, IRELAND sameer_vicky@hotmail.com

© 2012 PGIP. All rights reserved.

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 114

Effects of Whiplash Injury on Median Nerve Mobility: A Comparative Study Muhammad Nazim Farooq

Abstract Chronic pain following whiplash injury is a challenging condition for healthcare professionals. Clinical signs of changes in neural mobility have been observed in these patients, which may be responsible for symptoms. The present study used ultrasound imaging to

evaluate and compare median nerve movement in subjects who have

previously had a whiplash associated disorder (WAD) (n=7) with a control group (n=10). Longitudinal and transverse nerve sliding was measured at mid-forearm during neck movement from neutral to contralateral side flexion. Data were analyzed using descriptive and non-parametric statistical methods.Longitudinal nerve movement was reduced by 24% in WAD group compared with control group, where the mean movement was 1.31 (SD=0.49) mm and 1.73 (SD=0.92) mm respectively. Transverse movement was reduced by 66.7% in patient group compared with control group, where the mean movement was -0.06 (SD=0.51) mm and -0.18 (SD=0.54) mm respectively.

Overall there was a trend of reduced nerve sliding in whiplash patients but this did not achieve statistical significance. Further research should utilise a larger sample to further evaluate the nature and extend of changes in neural mobility in a patient population.

Keywords: Whiplash; Median nerve; Ultrasound imaging; Nerve movement.

Introduction

number of people who go onto to

Whiplash injuries are an increasing

develop chronic pain and disability.1-3

public health problem due to the

Most individuals following a whiplash

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 115

injury recover in 2-3 months4 but a

neural or associated tissue can elevate

significant

(14-42%)

mechanosensitivity thresholds in the C

experiences persistent ongoing pain

and Aβ fibers12,15-18 and has been

with 10% reporting constant severe

detected during normal physiological

pain.5 It is this group with persistent

movements of the peripheral nerves.16,17

symptoms who form the major part of

In addition to mechanical compromise,

the significant economic costs related to

peripheral nerves may be damaged as a

proportion

this disorder. of

2,6,7

Despite the availability

numerous

epidemiological

result of the excessive forces during a hyper-extension-flexion

injury

the

associated with WAD.12 Minor nerve

persistence of disabling symptoms are

injury and loss of nerve mobility may

not clear.8 One of the possible reasons

produce the symptoms of the patients.

could

19,20

publications,

be

the

the

reasons

lack

for

of

sufficient

information about the mobility of neural

Chronic whiplash patients may have

tissues in relation to its surrounding

neurological symptoms without obvious

structures.

signs

of

nerve

damage.

the

Neurophysiological investigations, such

be

as EMG and nerve conduction studies,

the

are often normal in these patients11,12

scalenes and pectoralis minor muscle

which made it difficult to determine the

following

cervical

exact pathology. As a consequence,

region9,10 resulting in changes to the

there has been considerable interest in

neural

investigating the physical characteristics

It

has

been

suggested

neurovascular mechanically

bundle

that may

compromised

trauma

tissue

to

along

the

its

by

peripheral

pathway.11,12 The viscoelastic properties

of nerve by using ultrasonography.

of nerves allow them accommodate to

Whilst early in vivo studies relied on

changes

without

invasive procedures of needle insertion

compromise or strain.13 Bilecenoglu et

to detect nerve movement,21 high

al14 suggest that restriction to normal

resolution ultrasonography and image

nerve sliding relative to adjoining

analysis has enabled researchers to

tissues/structures

quantify transverse and longitudinal

in

limb

pathophysiological

posture

could changes

lead

to

in

the

peripheral nerve motion (e.g. 20,22-24).

peripheral nerve. Inflammation of the

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 116

Signs of altered nerve movement and

in WAD patients, both locally and

changed neural mechanosensitivity have

remote to the site of injury, indicative of

24

central sensitization. The notion of

been reported in whiplash patients.

Painful responses have been found in

aberrant

patients having whiplash injury during

mechanisms

neural sensitizing manouevres; these

symptoms in chronic WAD is further

tests (e.g. ULTT1) assess the mobility

supported by many other studies.28-32

of peripheral nerves relative to adjacent

Greening

tissue.11,24,25 A positive finding (pain,

proximal nerve sliding in both whiplash

muscle

is

and non specific arm pain (NSAP)

indicative of pathophysiology of the

patients during a deep breathing which

peripheral

nerve

associated

with

function.

spasm,

26

paraesthesia)

central

et

as

al24

pain a

processing

contributor

found

to

decreased

and

has

been

they associated with reduced first rib

changes

in

nerve

excursion. However it is not clear

of

whether this reduced proximal nerve

(positive

sliding is due to reduced first rib motion

Tinels sign at the supraclavicular fossa)

or altered environment around the cords

and decreased pain threshold to digital

of the brachial plexus at thoracic outlet.

pressure have also been reported in

Due to the sample size and lack of

WAD patients over sites along the

clarity around the sample characteristics

course of the median nerve and cords of

it is difficult to derive any meaningful

brachial plexus.11,24,27 It is suggested

conclusion from this study.

that altered nerve tension and neural

Whilst Dilley et al26 reported a trend of

mechanosensitivity may contribute to

reduced proximal nerve sliding (17.9%)

symptoms in patients having whiplash

in a NSAP group compared to a control

brachial

injury.

Additionally plexus

irritation

signs

24

group, the results failed to achieve

As well as evidence from the peripheral

statistical significance. It may be due to

nervous system, evidence exists to

small sample size which might lack the

implicate the central nervous system

power to detect population effects that

(CNS)

are practically important.33

as

a

contributor

to

the

perpetuation of symptoms in chronic WAD. Sterling et al

27

The aim of this study was to evaluate

reported a global

the longitudinal and transverse sliding

decrease in mechanical pain thresholds

of the median nerve at the mid forearm

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 117

during contra lateral neck side flexion

correlation coefficient [ICC] = 0.39â&#x20AC;&#x201C;

(CNSF)

have

0.76) for measurement of transverse

whiplash

sciatic nerve movement and excellent

in

previously

subjects

who

experienced

a

injury and those who have not.

reliability (ICC = 0.75) for analysis of longitudinal movement.34

Methodology

Procedure

Study design

A

A single blinded quasi experimental

physiotherapist

different subject design was used.

ultrasound image acquisition.

Sample

A pilot study was conducted to assess

Convenience sample of seven WADII

feasibility of procedures prior to main

(2 male and 5 female) and ten non

study.

WAD subjects (5 male and 5 female)

Subjects were positioned in supine lying

were recruited. Ethical approval with

with cervical spine in neutral. The

adherence to institutional Research

testing arm (the most symptomatic arm

Governance Guidelines was gained with

in whiplash group and dominant arm in

all subjects giving informed consent.

control group) was supported on a

Subjects

Perspex plate with; 30-degrees shoulder

with

known

trained

musculoskeletal performed

abduction,

systemic conditions including diabetes

supinated forearm24 and the wrist and

and

digits fixed in neutral with external

who

had

had

upper

extended

the

neuromusculoskeletal spine conditions,

those

fully

all

elbow,

limb/neck surgery or were pregnant

supports23 (fig. 1).

were excluded from the study.

Prior to testing, participantsâ&#x20AC;&#x2122; necks were

Equipment

moved into CNSF six times whilst

Ultrasound imaging was performed

maintaining the upper limb position to

using a Diasus ultrasound system

ensure that stability of nerve motion had

(Dynamic

Livingston,

occurred.35 Longitudinal and transverse

Scotland, UK) with a 8-16MHz, 26mm

images of the median nerve at the mid

linear array transducer as previously

forearm were acquired, first with the

Imaging,

described by Dilley et al.

22,23

Ultrasound

head in neutral position then with the

imaging has been shown to have fair to

neck movement into contralateral lateral

excellent

flexion (CLF) where this manouevre

reliability

(Intraclass

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 118

has been shown to tension the median

apart and could be seen on the

nerve.23,36,37 The nerve motion was

ultrasound images as bright lines which

initiated by taking cervical spine of the

cast an acoustic shadow across the

subject into CLF to the first point of

image. Images were acquired in neutral

resistance (R2) by the research assistant

position and CLF position. Median

or where symptomatic to first point of

nerve location was measured relative to

pain

these markers using the tpsDig program

(P1).

Range

of

CNSF

was

measured by using a protractor scale on

(F.

a sheet of white paper under the

Ecology and Evolution State University

participants head.

of New York). The nerve co-ordinates

Longitudinal median nerve imaging

were measured on frames taken during

The sequences of ultrasound images

the rest period at the start and end point

acquired from the mid forearm during

of each image sequence. The horizontal

CNSF were captured as a cine loop at

and vertical distances of the centre of

10 frames/s using a Diasus ultrasound

the nerve from the markers were then

system (Dynamic Imaging, Livingston,

determined

Scotland, UK). The image sequences

Change in nerve position was measured

were analyzed offline using software

by subtracting the values with head in

developed in Matlab (Mathworks, USA)

neutral position from those with neck in

that employs a frame-by-frame cross-

contralateral side flexed position. The

correlation algorithm.

22,23

James

Rohlf,

from

Department

the

of

co-ordinates.

Resolution of

co-ordinates were defined such that

the images was 96 dpi and image size

positive values for horizontal movement

was 596 by 796 pixels.

indicate

Transverse median nerve imaging

direction while positive values for the

Transverse images were also acquired at

vertical

mid forearm (fig. 2). The surface of the

movements.

skin was marked using thin (2 mm

After taking the measurements, NPT

wide)

(Fixamull,

(median nerve bias)38 was performed on

Beirsdorf) as used by Greening et al.24

both sides to assess the median nerve

These strips were applied along long

involvement and the range of elbow

axis of the ventral surface of forearm.

extension was measured by using a

Two strips were positioned 10â&#x20AC;&#x201C;17 mm

Universal

strips

of

tape

movement

measures

in

the

radial

indicate

Goniometer.39

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

dorsal

The

NPT

Page 119

(median nerve bias) has been shown to

utilized to explore differences between

tension the median nerve and brachial

two groups (control and WAD).

40,41

plexus.

The test was considered

positive if it reproduces symptoms and

Results

demonstrates a restriction in the range

The demographic details and clinical

of elbow or wrist extension. If the

findings of NPT (median nerve bias) for

symptoms of a patient can be altered by

both groups are included in table 1. The

adding

distal

NPT (median nerve bias) was found

component of the specific technique, the

positive in two whiplash patients, which

subsequent response may be due to

may suggest the corresponding nerve

changes in the corresponding neural

tissue involvement.

or

subtracting

system mechanics.

a

38,42

Reliability

Data analysis

Individual

data

were

horizontal movements were 0.96 and

the

mean

0.92 respectively which shows excellent

longitudinal and transverse motion of

reliability according to Portney and

the median nerve during CLF.

Watkins43 where poor (r < 0.50),

To assess the reliability of the off line

moderate (r = 0.50 - 0.75), good (0.75 <

data analysis, inter-rater reliability was

r > 0.90), and excellent (r > 0.90).

performed on the individual data on 3

Longitudinal nerve sliding

different occasions and analyzed using

In

an intraclass correlation coefficient

proximally during CNSF. The mean

(ICC) (3, 1). The mean measure from 3

nerve excursion was 1.73 mm (SD =

occasions was subsequently used for the

0.92) in control subjects (n=10) and

descriptive data analysis for each group.

1.31 mm (SD = 0.49) in whiplash

The range of nerve motion, including

patients (n=7). Although there was a

means and SD for the WAD and control

reduction of 24% in nerve movement in

group was calculated. All data analysis

the whiplash group compared with

was performed using SPSS version

control

17.00, where p < 0.05.

significant difference between groups (P

For inferential data analysis, the non

=0.20, Mann-Whitney U test).

analyzed

and

The ICC (3, 1) for longitudinal and

to

group quantify

all

subjects

group

the

but

nerve

there

moves

was

no

parametric Mann Whitney U test was

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 120

The Figure 3 shows comparison of

The angle of neck side flexion was not

longitudinal nerve movement between

significantly different between groups

whiplash and control groups. In control

(P = 0.38, Mann-Whitney U test) with

group 50% subject have movement

mean angle 53.6 (SD = 4.7) degrees in

more than 1.51 mm, where as in

control group and 49.6 (SD = 7.61)

whiplash group only one subject (outlier

degrees in whiplash group.

in the graph) has more movement than this.

Discussion

Transverse nerve sliding

The present

In 8 of 10 control subjects the median

reduction in longitudinal motion and

nerve moved toward ulnar side and in

66.7% in transverse motion in median

remaining 2 subjects it moved toward

nerve at the mid forearm during CLF in

opposite direction. In control group the

WAD compared to a control group.

mean nerve translation was -0.18 mm

Whilst these results did not achieve

(SD = 0.54) and the nerve movement

statistical significance, the trend for a

ranged from -0.82 mm in ulna direction

reduction of neural motion in WAD

to 1.04 mm radially (the negative sign

subjects does support the findings of

indicates movement in ulna direction)

Greening et al.24 The differences could

(fig. 4).

be accounted for based on WAD

In 3 of 7 subjects in whiplash group the

subjects characteristics, as those in

median nerve moved radially and in

Greening et al.â&#x20AC;&#x2122;s study24 had a positive

remaining 4 subjects it moved toward

NPT (median nerve bias), where the

opposite direction. In this group the

current study only had 2 subjects with a

mean nerve translation was -0.06 mm

positive NPT (median nerve bias).

(SD = 0.51) and the nerve movement

The

ranged from -0.59 mm toward ulna

movement of the median nerve in the

direction to 0.74 mm radially. There

present study was variable with no

was no significant difference between

direction preference noted. Greening et

two groups (P = 0.63, Mann-Whitney U

al24 however found the median nerve to

test), despite a reduction of 66.7% in

move radially. This may be due to

transverse nerve translation in whiplash

differences in the anatomy at the

group compared with control group.

measurement sites, where the fascial

direction

study found

of

the

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

a 24%

transverse

Page 121

bands and adjacent parallel orientated

along the median nerve and cords of

tendons of the carpal tunnel may

brachial plexus) have been found in

constrain or limit movement to be

whiplash patients.24 Diffuse arm and

uniform during.

neck pain may be due to change in

The present findings showed a trend of

nerve environment at the thoracic outlet

reduced proximal nerve sliding in WAD

and carpal tunnel, which may lead to

compared

subjects,

localized inflammation. Inflammation

suggesting that probably there may be a

of the nerve or surrounding tissues can

restriction to median nerve proximally.

lead to increased mechanosensitivity of

It is possible that variability between

nerve fibers, 12, 15-18 responding to small

subjects may mask small trends. The

pressure and stretch. This may explain

results of this study are in agreement

the

with the findings of previous study in

suggest nerve mechanosensitivity rather

patients

with

with

control

NSAP

26

trunk

hyperalgesia

and

also

than frank nerve entrapment may result

showed a trend of reduced proximal

in painful responses while examining

nerve sliding (17.9%) in patients that

the neurodynamics in whiplash patients,

failed to achieve statistical significance.

when the longitudinal nerve excursion

It may indicate that median nerve

appears to be within normal range.

restriction can play a role in producing

Central

symptoms of patient.

considered to play a role in symptom

As WAD II patients were considered for

production in whiplash patients with

the present study, restriction of the

neuropathic pain.28-32 It depends upon

median nerve sliding cannot be ruled

maintenance

out in other sub-groups of whiplash.

nociceptive input.44,45 In the normal

As the present study did not find

pain state both peripheral nervous

significant difference in longitudinal

system afferent and central nervous

nerve excursion between two groups,

system hyperexcitability occurs.37 In the

therefore alternative mechanisms for

presence of central hypersensitivity,

symptoms

be

either no or minimal and undetectable

considered. Signs of increased nerve

tissue damage is required to induce

trunk

pain.45 This may explain the reason of

production

mechanical

which

nerve

must

sensitivity

(e.g.

sensitization

of

has

ongoing

been

local

allodynia to digital pressure over sites

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 122

pain in the absence of evident tissue

but also within the groups, as done by

damage.

previous researchers (e.g. Greening et

There are a number of limitations with

al24).

the current study. Lack of statistical significance may be due to use of

Conclusion

nonparametric

less

Both longitudinal and transverse nerve

sensitive in picking up significant

movements were reduced by 24% and

test

which

is

differences than parametric test

33,46,47

66.7% respectively in WAD compared

and the small sample size which might

to control subjects but no statistically

lack the power to detect population

significant

effects that are practically important.33

between groups. Future research, using

Furthermore, the presence of outliers in

larger sample size and involving other

the patient group (nerve movement =

subgroups of WADs, is warranted to

2.29 mm) for longitudinal movement

further explore the nature and extent of

and control group (nerve movement =

neural tissue motion in a patient

0.24 mm) for transverse movement can

population. In addition to this, the

markedly influence the results from

central

statistical analysis.

33

difference

sensitization

was

needs

found

to

be

explored further to find out its role in

The sample size was small which may

symptoms production in this population.

cause type II error47 and can decrease

This

the power of statistical analysis.48 A

understand

convenience sample was used instead of

pathophysiology of this challenging

random sampling due to constraints of

condition and would enable them to

time and resources, which reduces the

treat it more effectively.

external

validity

of

the

may

help

the

clinicians

the

to

underlying

findings.

Parametric data analysis methods are

Acknowledgements

more sensitive to detect differences;

The author is grateful to Nicola

however the current study did not fulfill

Heneghan for her enriching comments

the prerequisites for these tests.

33,47

and invaluable support.

Imaging should be performed on both sides in both groups in order to find the differences not only between the groups

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 123

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Page 127

Table 1: Subjects demographic details and clinical findings for upper limb tension test 1 (ULTT1): n, number of subjects; M, Male; F, Female; SD, Standard deviation; +, test positive; -, test negative.

Group

n

Gender

Mean age (SD)

Mean height (SD)

Mean

weight (SD)

ULTT1 (years)

(cm)

(kg)

2M, 5F

34.71 (12.72)

169.79 (7.38)

76 (13.76)

5M, 5F

25.10 (1.45)

171.30 (9.69)

69.80

+/-

Whiplash

7 2/5

Control

10

(15.33)

0/10

Fig. 1: Arm for ultrasound imaging: shoulder abducted 30ยบ, elbow fully extended, forearm supinated, wrist and digits in neutral position.

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 128

Radial Ulnar

Ulnar

Radial

A B Fig. 2: Transverse images of the median nerve taken at mid forearm. Acoustic shadows across the images represent markers. Six red spots, two on markers and four on the nerve were placed to measure the location of the median nerve with respect to the marker. A) Median nerve image with head in neutral position, B) Median nerve image with neck in contralateral side flexed position; the movement of median nerve towards ulnar side is clearly demonstrated.

Fig. 3: Comparison of longitudinal nerve movement at mid forearm during contralateral neck side flexion across whiplash and control groups. Circle represents outlier.

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 129

Fig. 4: Comparison of transverse nerve movement at mid forearm during contralateral neck side flexion across whiplash and control groups.

Circle represents outlier.

Available online at www.pgip.co.uk/jopsm POSTGRADUATE INSTITUTE OF PHYSIOTHERAPY

Address for correspondence: Muhammad Nazim Farooq Islamabad College of Physiotherapy Margalla Institute of Health Sciences Quaid -e- Azam Avenue Gulraiz III, Rawalpindi Pakistan nazimfarooq@yahoo.com +92-300-4269864

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Hand: Fundamentals of Therapy. 3rd ed.

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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.

not suitable for figures, tables, or text.

numbered

6

end

tables

of

consecutively,

and

figures

Appendixes

the

and

(total).

should

manuscript.

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Use

Chronic diseases and associated risk factors

[document

on

the

Internet].

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

Available online at www.pgip.co.uk/jopsm POSTGRADUATE INSTITUTE OF PHYSIOTHERAPY

Available from: http://www.aihw.gov.au/cdarf/index.cfm 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

The Journal of Postgraduate Institute of Physiotherapy

[Internet]. 2008 [cited 2009 Aug 12];

Visit the journal website at

11(3):

259-64.

Available

from

http://www.pgip.co.uk/jopsm

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

Book Chapter

Jones MA, Rivett DA. Introduction to clinical reasoning. In: Jones MA, Rivett DA, eds. Clinical Reasoning for Manual Therapists. Edinburgh, UK: Butterworth Š 2012 PGIP. All rights reserved

[Journal of Physiotherapy & Sports Medicine][Volume 1][Issue 2][December 2012]

Page 119

At Postgraduate Institute of Physiotherapy, we are the team of professional physiotherapists working in United Kingdom promoting and uplifting 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.

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www.pgip.co.uk

Encouraging Better Education Call of Articles Call for articles for the June 2013 Third Edition of the Journal of Physiotherapy & Sports Medicine (JOPSM) is currently being made. The closing date for receipt of submissions is May 30th, 2013. Thank you to all who have submitted to our previous editions. Full details of how to submit your work are available at:www.pgip.co.uk/jopsmWe look forward to receiving your submissions and wish to thank you, as always, for your assistance in producing the Journal of Physiotherapy & Sports Medicine (JOPSM).

JOPSM