IJRS Volume 01, Issue 01, January - June 2012 by waqar awan

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

Volume I, Issue I

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

Volume I, Issue I

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

Volume I, Issue I

Editorial Board Editor In-chief

Dr. Muhammad Naveed Babur (PT, DPT) Full Member WAME (USA)

Managing Editor Dr. Waqar Ahmed Awan (PT, DPT) Associate Editors o o o o o

Dr. Shaukat Ali (PT, DPT) Dr. Usman Iqbal Janjua (PT, DPT) Mr. Akhtar Rasul (PT, MCSP, MISCP) Mr. Muhammad Bin Afsar Jan (MSPT-AUS) Dr Muhammad Ashfaq (PT-DPT)

Technical Reviewers o o

Mr. Hazrat Umer (Ph. D Scholar) Mr. Hannan Adeel (MS)

National Advisory Board

International Advisory Board

Mr Salabat Ali Khan (ZMU) Dr Farah Rashid (SCM) Dr Muahammad Asif Shiekh (IUKC) Mr Faisal Hayat Khan (PCB, National Cricket Team) Dr Qamar Mehmood(NIRM) Dr Arshad Nawaz Malik (RIU) Dr Furqan Ahmed Siddiqui (RIU) Dr Muhammad Mannan Haider (PSB) Dr Syed Shakil-ur-Rehman (RIU) Mr. G M Bodla (NIRM) Miss. Bushra Ambreen (NIRM) Mrs. Rehana Noor (NIRM) Dr Rabnawaz Khan (BBH) Mr Muhammad Kashif (SIH) Dr.M.Yasir Saeed(FFH) Mr Ashfaq Ahmed (UOL) Dr. Salman Ikram (FFH) Dr. Raheela Kanwal (RIU) Mrs Sadaf Noveen (AIOU) Mr Nasir Khan (NIRM) Ms.Fazaila Sabih(RIU) Mr Syed Irtaza Amir Hasan Kazmi (AFIRM)

Dr.Javed Nouman.PhD.PT(Norway) Dr Muhammad Fahad Siddiqui (Malaysia) Dr Shahzada Junaid Amin (KSA) Miss Arjumand Mahmood (Belgium) Mrs Noreen Kausar (UK) Dr. Kaukab Mazhar (Canada) Dr Asma Tanvir (UK) Dr Abdul Hakeem Atif (Australia) Mr Danish Rasool (UK)

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

Volume I, Issue I

In Collaboration With

Isra University Hyderabad, Karachi & Islamabad www.isra.edu.pk

Pakistan Physical Therapy & Rehabilitation Consultants www.pptrc.org.pk

National Rehabilitation Conference 2012 www.nrc.org.pk

Isra Institute of Rehabilitation Sciences (IIRS), Isra University Islamabad Campus

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

Volume I, Issue I

International Journal of Rehabilitation Sciences (IJRS) The IJRS, published biannually, is a peer reviewed scientific publication in the field of rehabilitation sciences. The journal welcomes manuscripts in the areas of Physical Therapy, Orthotics and Prosthetics, Occupational Therapy, Rehabilitation Medicine, Exercise Physiology, Speech Therapy, Audiology, Community Based Rehabilitation Intervention, Clinical Psychology, Inclusive & Special Education. IJRS engages and inspires an international & national readership on topics related to rehabilitation sciences. As a leading journal of Pakistan for research in rehabilitation sciences and related fields, IJRS publishes innovative and highly relevant content for both clinicians and scientists and uses a variety of interactive approaches to communicate that content, with the expressed purpose of improving patient care.

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

Volume I, Issue I

PREFACE It gives me immense pleasure to write about the International Journal of Rehabilitation Sciences, which is going to be a great mile stone and a revolutionary step forward in the field of rehabilitation sciences. It will not only help promote the science and art of Rehabilitation sciences but also will provide services for the betterment of the community and uplift the field of health sciences. It is a sign of commitment to reflect the highest standards of editorial integrity independent of any special interests. It possesses highly innovative, technology driven, credible and enjoyable to read information , enabling rehabilitation practitioners to remain well informed about latest developments and trends not only in their respective areas of interest but also other than their own. It is also a valuable tool for the health care professionals to get up to date knowledge for the continuing professional development in the basic as well as clinical sciences to support their clinical decision making skills and ongoing career development. I wish the whole editorial board/committee members the very best for the future endeavors and hope that they will work with more zeal and spirit in time to come.

Akhtar Rasul (PT, MCSP, MISCP) Associate Editor IJRS Assistant Professor/ In-charge Department of Physical Therapy Sargodha Medical College, University of Sargodha.

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

Volume I, Issue I

Table of Content S. #

Title

Editorial

The Effectiveness Of Manual Physical Therapy In The Treatment Of Sub Acute And Chronic Cervical Spine Pain

The Effectiveness Of Electrotherapy With Manual Therapy In The Treatment Of Piriformis Syndrome

Page

Trends Among The Physical Therapists About The Use Of Functional Status Assessment Tools: A Cross Sectional

Survey 5.

The Prevalence Of Chronic Low Back Pain In Office Workers Of Lahore Medical And Dental College And Ghurki

Trust Teaching Hospital, Lahore 6.

The Effectiveness Of Sustained Stretching In Post Stroke Upper Limb Spasticity

The Role Of Stretching Exercises In Relieving Constipation In Spastic Cerebral Palsy

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

Volume I, Issue I

Editorial A Journey from Post Matriculation Diploma to Post Professional Clinical Doctorate: A Historical Perspective of Physical Therapy Profession in Pakistan Muhammad Naveed Babur, Muhammad Ashfaq

Physical Therapy or Physiotherapy is a health care profession that provides treatment to individuals to develop, maintain and restore maximum movement and function throughout life. This includes providing treatment in circumstances where movement and function are threatened by aging, injury, disease or environmental factors. Started by technicians with a diploma course, the physical therapy profession now boasts confident, accomplished and professional practitioners at the cutting edge of health care, and may be ranked as one of the most popular careers of today in Pakistan and worldwide. Historically speaking, the journey from Post matriculation Diploma to Post Professional Doctorate was not so swift; it took almost fifty years to attain the current level of professional education and recognition by society. The first school of physiotherapy was established at JPMC in 1956 by Ministry of Health (MOH) in collaboration with World Health Organization (WHO) and a two-year diploma course in physiotherapy with entrance requirement matriculation (science) was started. In 1961 this two-year diploma program was upgraded to a three years diploma course in physiotherapy. Just after two years i.e. in 1963, the first school of physiotherapy in Pakistan was affiliated with University of Karachi and three-year diploma program was upgraded to a three-year B.Sc. Physiotherapy degree course with entrance requirement of F.Sc. (pre-medical). The conversion of diploma to degree was perhaps the first jump towards professional status. The Second School of Physiotherapy was established at Mayo Hospital Lahore in 1986, affiliated with university of Punjab offering a three-year B.Sc physiotherapy program. Since then there was a status quo, the physiotherapy community in Pakistan was perhaps very happy, as achieving B.Sc. physiotherapy degree was a guarantee for an overseas placement. But with passing time credential requirements for physiotherapists were continuously changing and getting jobs abroad became hard for Pakistani degree holders. It was in 1999 when the three-year B.Sc. physiotherapy program in both public sector institutions was upgraded to BSPT four-year program. But now there are 22 institutions offering entry level degree programs throughout the country, six of these offering entry levels DPT program.

The rest of the institutions offer a four-year B.Sc

physiotherapy degree program convertible to DPT. Some public and private universities including Riphah, Isra, KEMU and UHS offer a two-year Post Professional Doctor of physical therapy/M.phil programs for practicing physiotherapists. It is worth mentioning here that the Higher Education Commission constituted National Curriculum Committee for Physical Therapy, who approved a National Curriculum for entry level doctor of physical therapy. To cope with the international standards is a difficult task in a developing country in every perspective of the profession. Most of the institutions are lacking standardized teaching environment and facilities. Lack of competent mentors and teachers is also a major problem of every institution, resulting in the professionalsâ&#x20AC;&#x2122; lack of the necessary skills needed for a good practitioner in the field. Unfortunately, there is no central regulating authority in Pakistan. Instead some local societies and associations like Pakistan Physical Therapy Association (PPTA) (WCPT member), Pakistan physiotherapy Society (PPS), and Charted Society of Physical Therapy (CSP) exist but their contribution in professional growth is not much visible; On the

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International Journal of Rehabilitation Sciences (IJRS)

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issues of public health, primary and preventive health like polio eradication, maternal and infant health issues, obesity, diabetes, heart diseases, malaria and AIDS control etc. their participation at community and national level is almost negligible. Similarly on matters of job creations, service/ career structure these associations and societies remain silent; however the role of private sector organizations is appreciable in many aspects of the professionâ&#x20AC;&#x2122;s growth. These organizations have their own limitations like lack of funds, proper leadership, and coordination among the professionals and associations as well. However International Journal Of Rehabilitation Sciences (IJRS) is the first ever journal of rehabilitation sciences in Pakistan. It is a milestone and a great contribution to promote research & development in this field. In spite of very sluggish pace, physiotherapy as a profession has progressed and taken many incremental steps; and still heading a Journey from Post Matriculation Diploma to Post Professional Doctorate and M.Phil. All that is needed is the commitment to the profession, to the community and to us; and passion for growth as the passion persuades.

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

Volume I, Issue I

THE EFFECTIVENESS OF MANUAL

in disability scores, based on perceived recovery was

PHYSICAL THERAPY IN THE

29.5% for manual therapy including manipulation and mobilization, which is higher than successful rate for

TREATMENT OF SUB ACUTE AND

electrotherapy

CHRONIC CERVICAL SPINE PAIN

(23.9%).

Manual

therapy

scored

consistently better than electrotherapy as outcomes.

Authors; Muhammad Shoaib, Muhammad Naveed

Conclusion:

Babur, Akhtar Rasul

recommendations made with confidence regarding the

The

results

suggested

that

the

use of manual therapy are good option for the

Abstract

management of neck pain. In Future similar trails

Objectives: To determine the effectiveness of manual

should be examined for the value of manual therapy

therapy in neck pain and to contribute to physical

for neck pain

therapy literature for new research. Neck pain is a

Key words: Neck pain, manual therapy, effectiveness,

common complaint with high prevalence and is

electrotherapy, neck disability index, randomized

sometimes associated

control trail.

with shoulder and / or

headaches. To treat the neck pain various interventions are being used by physical therapists which may include

electrotherapy,

exercise

therapy,

neuromobilization, traction & manual therapy. Study Design: RCT (Randomized control trial) included forty patients in total who were divided into two groups of twenty patients in each, receiving manual therapy and electrical therapy evaluated by using patient orient primary outcome measures (Neck Disability Index). The Patients were selected at EERA (MRDEA) Centre, physical therapy and neurology department in Abbas Institute of medical science Muzafrabad, AJ&K, Pakistan. Methods: Forty patients suffering for at least 2 weeks from neck pain were randomized to receive a 6-week treatment

strategy

manual

therapy

and

electrotherapy three a week. The primary outcome measures were perceived recovery and functional disability. Results: In 6 weeks a considerable decrease in disability scores was observed for manual therapy treatment for all outcomes. The success rate, decrease

Introduction Neck pain is a very widespread problem; next to low back pain in its frequency in the general population and in musculoskeletal practice

[1].

Neck or cervical

pain has a prevalence of 67% in young adults. Approximately 15% of females and 10% of males suffer from chronic neck pain at any one time in their life span

[2].

25% of Patients seen in outpatient

physical therapy are referred for treatment for cervical pain

[2].

Chronic neck pain produces a high level of

morbidity by affecting occupational and vocational activities of daily living and by affecting quality of life. Non-specific neck pain, which could not be linked to prior injury or illness, was found to be the most frequent symptom in a broad survey of employees of the Finnish Broadcasting Company. The point prevalence for frequent or continuous neck pain was 38%

[3]

. Though this survey was not conducted in

Pakistan but it shows the prevalence of non-specific neck pain. Neck pain may be highly disabling and costly, while little is known about its clinical course [4, 5]

. Decreased range of motion and a subjective feeling

of stiffness may accompany neck pain, which is often

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International Journal of Rehabilitation Sciences (IJRS)

Volume I, Issue I

provoked by neck movements or sustained neck

aerobic and musculoskeletal capacity. The variable

postures. Headache, dizziness, and other signs and

age is also related to the number of years the workers

symptoms may also be present in combination with

spent in their work, and this increases exposure time to

neck pain

[6, 7]

. Although history taking and diagnostic

other probable possible risk factors. Although a little

examination can suggest a potential cause, in most

evidence has shown that musculoskeletal disorders and

cases the pathologic basis for neck pain unclear and

injuries, accidents, sickness and absences are more

the pain labeled is nonspeciďŹ c.

common among younger workers

At present, no classification criteria exist that are

these studies prevalence has also been reported with a

suitable for use in population-based studies in

peak in mid- life. [12].

classifying neck pain, shoulder pain or cervical

One reason for this may be that females have less

headache or in combination form.

[8]

[11,12 ],

In some of

. Neck and

muscle mass and strength than males. Gender has been

shoulder pain have been defined in different ways in

considered in a number of studies as a possible risk

different

factor for the development of general health problems

studies:

ache,

discomfort,

stiffness,

numbness, tenderness, and myalgia are examples of

and musculoskeletal disorders.

words used. The incidence of pain and its fluctuation,

Occupation has a great influence on the factors that

intensity and duration in one episode or repetition in

can cause neck pain. Several studies show that the

different episodes, are other items in outcome

manual workers often have a higher incidence of neck

measurements. The Pain affects a personâ&#x20AC;&#x2122;s activities

and shoulder pain than office going. [10, 12].

(personal or work). Different symptoms like pain ache

Education may have a direct influence on health-

and stiffness cannot be separated in terms of where

related behavior: children who do well in education

they originate, so a separate anatomical description is

tend to report better behavior in adult life in terms of

necessary to the problem.

diet, smoking and exercise. A number of studies have

One trouble in risk dimensions is that in the real world

indicated that the prevalence of back pain is associated

it is hard to talk about individual risk factors

with a low educational level

separately. Most risk factors are not isolated: they

education may act as an indicator for other factors

overlap and work together. The use of diverse

such as socio-economic status, occupational level or

definitions for similar risk factors and similar

lifestyle.

definitions for risk factors that are completely different

Stressful events elevate hyperventilation, reducing

are common in the literature

[9]

[12]

. The level of

PCO2 in the arterial blood system. This phenomenon

The findings of studies on musculoskeletal disorders

eventually leads to an increase in muscle ischemia and

show that age is associated with the occurrence of

hypoxia. It also changes the potassium ions in the

musculoskeletal problems in different professional

blood and upsets muscle function. According to this

categories such as nursing staff railway workers and miscellaneous occupations.

[10,

11]

theory, the communication between sensory nerves

Age is often

and blood vessels dilate the blood vessels affecting the

understood to be correlated with musculoskeletal

muscles and causing pain similar to hit of migraine.

problems, such as physiological changes, for example

Various mechanisms have been described in this

decline in physical work capability, diminishing

regard [13].

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International Journal of Rehabilitation Sciences (IJRS)

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Long- term static load causes dysfunctions in the

therapy group. The decrease in the disability score in

muscle spindle system, by enhancing activity in nerve

work is substantial for the person to go early to work.

cells

[14].

In the electrotherapy group the disability scores have

According to this theory, prolonged head-down neck

also been decreased from 578 to 339 so the difference

flexion and psychological stress decrease intracellular

in disability is 239. The change is also good in 6

oxygen and nitric oxide elimination because of

weeks with electro therapy.

reducing capillary blood flow

[15]

Group 1: Pretrial Graphical presentation of individual disability scores and percentages

This was a single blind clinical randomized controlled trail. The participants of the study were from the out patients of physical therapy department and referred

pretrial scores and percentages

Materials and Methods

100 80 60

Pretest score

percentages

20 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

indoor patients from neurology ward. The participants of the study were from both male and female sides with the age ranges from 20 to 60yrs. The duration of

No. of Participants

Graph no. 1; Pretrial values for Group 1 Manual Therapy

the study was three months. Total 40 patients were selected for this experimental study from AIMS Hospital AJ&K .20 patients were in controlled group and 20 in experimental group. Sample was drawn through simple randomized sampling. Patients with neck pain at least two weeks before the therapy, aged between 20 and 60 years were included. The patients had cervical surgery in the past, Pregnancy, Whiplash trauma were excluded

Graph no.2; Pretrial values for Group 2 Electrical therapy, Where series 1 are the NDI scores and series 2 are the NDI percentages.

Results Post-trial graphical presentation of scores and percentages

The sample size was 40, 20 in control group and 20 in and experimental group manual therapy with their regular sessions).Their progress was measured after six-week continuous manual therapy regime and electrical therapy.

40 Post trial scores and percentages

experimental group (control group had electrotherapy

35 30 25

Series1

Series2

15 10 5 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 No. of Participants

In the graph 1 and graph 2 it is clear that there is a considerable change in the NDI scores. There is a decrease in disability scores as a whole that is 593 to

Graph no.3; Post-trial values for Group 1 Manual Therapy, Where series 1 are the NDI scores and series 2 are the NDI percentages

298. The score difference is 295 five that is a considerable change. With this change the disability as a whole has been changed in the patients with manual

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International Journal of Rehabilitation Sciences (IJRS)

the follow up three days per week. The difference

Post-trial graphical presentation of scores and percentages

Post-trial scores and percentages

Volume I, Issue I

achieved was 23.9% after 6 weeks.

45 40 35 30 25 20 15 10 5 0

To check the difference between means of the total Series1 Series2

disability score of the two groups, the group 1 and group 2, student t test was applied as it is the most

9 10 11 12 13 14 15 16 17 18 19 20

No. of participants

Graph no.4; Post-trial values for Group 2 Electrotherapy, Where series 1 are the NDI scores and series 2 are the NDI percentages.

appropriate test. The confidence interval was set to be at 95% with 38 degree of freedom. The resultant value came out to be statistically 100% significant showing that the difference between means does exist. Group 1

In the comparison the differences are not very much

corresponds to experimental group and group 2

substantial but in the manual therapy group the rate of

corresponds to control group, receiving manual

disability is decreased as a whole. In the manual

therapy and electrical therapy respectively.

therapy group, subjects went early in the work placement and also they went on the recreational activity. The subjects concerning with the desk job or the computer work have also more decrease in disability as compared with electrotherapy group. For the personal care again subjects in the manual therapy group have reduced disability as compared with electrotherapy. Pain is considered to be the most important factor, in both groups, it has been reduced but pain reduction in manual therapy group is more. Because the pain is the basic factor, the hinderance in all aspects of an activity and contribute more to the disability, so the subjects in the manual therapy show more reduction in the disability scale as compared to the subjects in the electrotherapy. Total score of the group 1 before the manual therapy was 59.3% of the total disability scale and it was reduced to 29.8% after 6 weeks of manual therapy treatment with the follow up of three times per week. The difference achieved in reduction in disability score was 29.5%. Likewise the total score of group 2 before the treatment of electrotherapy was 57.8% and it reduced to 33.9% after electrotherapy treatment with

Discussion This was a comparative study of manual therapy and electrotherapy

effectiveness

clinical

practice

cervical pain. It was found that manual therapy is more effective

than

electrotherapy,

and

the

results

consistently favored manual therapy on almost all out come measures. In addition, although manual therapy seemed to be more effective than electrotherapy, the differences were small for all outcome measures except perceived recovery. This is because perceived recovery combines other outcomes, such as pain, disability, and patient satisfaction; it may be a responsive outcome. The differences among groups in scores on NDI were small and are considered clinically important that is 56. In this issue, coworkers report the findings of RCT study examining the effectiveness of manual therapy, continuing care by a general practitioner with the patients of nonspecific neck pain that had been present for longer than 2 weeks. Manual therapy consisted of what

authors

coordination,

name

stabilization,

â&#x20AC;&#x153;eclecticâ&#x20AC;? muscular

mixture and

of joint

mobilization techniques. Physical therapy by other means primarily focused on active strength, ROM, stretching and electrotherapy. To prevent cross

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

Volume I, Issue I

contamination of interventions, physical therapy was

Livingstone (1967), Lewit (1977), Schultz (1977),

administered by therapists. NDI assessments were

Vernone (1982), Droz and Krot (1985), Turk and

taken and the success rate was 68.3% for those who

Ratkolb (1987), Mennell (1990), Rundcrants (1991)

received manual therapy, 50.8% for the participants

and many more. The literature suggests that cervical

who received physical therapy by other means and

spine manipulation and mobilization may affect for

35.9% by continued care. Referral for manual therapy

short-term relief with muscle tension headaches.[14]

appears to have the best outcomes. It seems that study

Although the differences are not large for all outcome

has some deficiency for example success was on a

measures, manual therapy seems to be an effective

multi factorial subjective scale. Because the study was

treatment option for cervical pain. It should be

not blinded so the patients can exaggerate the

recognized that the data were collected at only one

outcomes with the favor.

clinical site and by one physical therapist. Future

Previous studies failed to show the significant

studies are necessary to validate this studyâ&#x20AC;&#x2122;s results

differences between manual therapy and physical

and determine whether similar findings occur in other

therapy by other means. But it is clear from the

patient population with different treating clinicians.

previous studies and the present study that manual

Additionally, a validation study should include a long-

therapy outcomes are better than the other forms of

term follow-up and a comparison group to further

physical therapy. In the present study the outcome

investigate the effectiveness of manual therapy in neck

measures by manual therapy are: 30.85% decrease in

pain. If the manual therapy is validated, an impact

disability scores and 18.1% decrease in disability

analysis of application of the manual therapy on

scores by other means of physical therapy. The results

clinical practice patterns, outcomes, and costs of care

are not extraordinary but it supports the results of

should be investigated.

Koes and colleagues (1991) who compared the effectiveness

manual

therapy

including

manipulation and mobilization and physical therapy by other means

[15].

This study confirms their studyâ&#x20AC;&#x2122;s

findings that manual therapy is superior to physical therapy by other means. During the study it was also clear that the mobilization and manipulation, which are the passive components of the manual therapy are the main contrasts with the physical therapy by other means especially electrotherapy were considered the When figured out from other studies the results of and

manipulation

are

not

very

satisfactory for long term effects. There is a long list of studies that had been researched for neck pain manipulations

and

mobilizations

for

This study showed that the manual therapy methods especially manipulation and mobilization are effective treatment choices when compared with electrotherapy for the management of cervical pain either associated with headaches or radiation to arm. This study also observed the fact that both the treatment groups showed decrease in disability due to neck pain during the course of treatment but the manual therapy appeared to be a more effective treatment.

most important and effective components. mobilization

Conclusion

example

References: 1. Jan Lucas Hoving, PT, PhD, Bart W. Koes, PhD, Henrica C.W. de Vet, PhD, Danielle A.W.M. van der Windt, PhD, Willem J.J. Assendelft, MD, PhD, Henk van Ameren, MD, PhD, et al. (2002). Manual

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International Journal of Rehabilitation Sciences (IJRS)

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Therapy, Physical Therapy, or Continued Care by a

development of non-specific musculoskeletal pain in

General Practitioner for Patients with Neck Pain,

preteens and early adolescents: a prospective 1-year

Annals of Internal Medicine, Volume 136 • Number

follow-up

10, (713-714)

Disord 2007, 8:46

study.

BMC

Musculoskel

2. Mikkelsson M, Salminen JJ, Kautiainen H: Non-

10. Cardon G, De Bourdeaudhuij I, De Clercq D,

specific musculoskeletal pain in preadolescents.

Philippaerts R, Verstraete S, Geldhof E: Physical

Prevalence

fitness, physical activity, and self-reported back and

and

1-year

persistence.

Pain 1997, 73:29-35.

neck pain in elementary schoolchildren. Ped

3. Vikat A, Rimpela M, Salminen JJ, Rimpela A, Savolainen A, Virtanen SM: Neck or shoulder pain

Exercise Sci 2004, 16:147-157 11. Long A, Donelson R, Fung T. Does it matter

and low back pain in Finnish adolescents. Scand

which exercise?

Journal Public Health 2000, 28:164-173.

exercise for low back pain. Spine 2004; 29:2593–

4. Fairbank JC, Pynsent PB, "The Oswestry Disability Index." Spine 2000; 25(22):29402952 wervelkolom

2602. 12. Clare A, Adams R., Maher C. Reliability of

5. Van der EL, Lunacek PB, Wagemaker AJ. Manuele Therapie:

A randomized control trial of

behandeling

[Manual

Therapy: Treatment of the Spine]. 2nd ed. Rotterdam: Manuwel; 1993

McKenzie classification of patients with cervical or lumbar pain. J Manipulative Physiol Ther 2005; 28:122–127. 13. Spitzer WO. Diagnosis

the

problem (the

6. Diepenmaat ACM, Wal MF, de Vet HCW, Hirasing

problem of diagnosis): Scientific approach to the

RA: Neck/shoulder, low back, and arm pain in

assessment and management of activity related

relation to computer use, physical activity, stress,

spinal disorders. A monograph for clinicians. Report

and

of the Quebec Task Force on Spinal Disorders.

depression

among

Dutch

adolescents.

Pediatrics 2006, 117:412-416.

Spine 1987; 12:S16–S21.

7. Carroll LJ, Hogg-Johnson S, Velde G, Haldeman S,

14. Winner R, Fritz J, Irrgang J, Boninger M,

Holm LW, Carragee EJ, Hurwitz EL, Cote P,

Delitto A, Allison S. Reliability and diagnostic

Nordin M, Peloso PM, Guzman J, Cassidy

accuracy of the clinical examination and patient

JD: Course and prognostic factors for neck pain in

self-report measures for cervical radiculopathy.

the general population – Results of the bone and

Spine 2003; 28:52–62.

joint decade 2000–2010 task force on neck pain and its associated disorders. Spine 2008, 33:S75-S82.

15. Koes BW, Assendelft WJJ, van der Heijden GJMG,

8. Bostrom M, Dellve L, Thomee S, Hagberg M: Risk

Boater

LM,

Knipschild

PG.

Spinal

manipulation and mobilisation for back and neck

factors for generally reduced productivity – A

pain: a blinded review. 13A11 1991;303:1298-303.

prospective cohort study of young adults with neck

16. Childs JD, Piva SR, Fritz JM. Responsiveness

upper-extremity

musculoskeletal

symptoms.

Scand J Work Environ Health 2008, 34:120-132 9. El-Metwally

Salminen

JJ,

Auvinen

of the numeric pain rating scale in patients with low back pain. Spine 2005; 30:1331– 1334.

Macfarlane G, Mikkelsson M: Risk factors for

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

Volume I, Issue I

THE EFFECTIVENESS OF

Therapy and TENS

ELECTROTHERAPY WITH MANUAL

Introduction

THERAPY IN THE TREATMENT OF

Most of the time in sports medicine regular stretching

PIRIFORMIS SYNDROME

and manual therapy, like techniques of soft tissue

Authors; Waqar Ahmed Awan, Muhammad Naveed

mobilization approaches, tell a greater decrease and

Babur, Shaukat Ali, Usman Janjua

elimination of piriformis syndrome.1,2,7 The greatest success occurs when the client commit to a daily home

Abstract

stretching protocol.3,4 Before stretching the piriformis of

muscle it is important to mobilize the capsule and

electrotherapy with manual therapy in the treatment of

surrounding muscles of the hip joint to gain effective

piriformis syndrome.

stretching of the piriformis muscle.5,6 The two MT

Methods: In this study which was conducted at

techniques

Physical therapy department of Family Health

management of piriformis syndrome are counter-strain

Hospital

and facilitated positional release. Both techniques are

DHQ

helpful to reduce the tension from the piriformis

for a period of two years, 50

muscle to a great extend.11,12 In an acute exaggeration

patients with piriformis syndrome were divided into

of symptoms, the client must stretch every two to three

two groups; a Control group which underwent

hours in a day. This will help in learning to return to a

electrotherapy treatment (Ultra sonic Therapy -US,

relaxed state. After symptoms subside, it is necessary

Short wave Diathermy-SWD & Transcutaneous

to continue the stretching exercises to reduce the

Electrical nerve Stimulation-TENS) and Experimental

return of habitual patterns that may have created this

group which underwent Manual Therapy treatment

syndrome

(Soft Tissue & Joint Mobilization Techniques and

clinical trial due to which no consensus is found about

stretching exercises). Both groups had regular

the overall treatment of piriformis syndrome. But

physical therapy sessions for 3 weeks; all participants

mostly manual therapy techniques and stretching are

were taught and practiced home care plan. The

considered to be effective treatments.14,15,18

Objective:

compare

Islamabad,

Rehabilitation

Medicine

Hospital Mansehra

the

effectiveness

National

Institute

Islamabad

and

most

4,8,9,17

commonly

reported

for

the

. There is also a lack of objective

progress of the patients was measured on modified Oswestry scale, based on the subjective evaluation of

Subjects and Methods

the patients in their activities of daily life.

The study was conducted at Physical Therapy

Results; Total disability post-test scores were lower in

Department of National Institute of rehabilitation

experimental group than control group.

Medicine

Conclusion;

Soft

tissue

and

Joint

mobilization

Islamabad

Islamabad, and

Family

District

Health

Hospital

Headquarter

Hospital

Techniques along with stretching exercises are of better

Mansehra for a period of two years. Fifty subjects with

choice when compared with electrotherapy treatment

piriformis syndrome were participated in the study and

in patients with pain due to piriformis syndrome.

were divided randomly in two groups; a control group

Key words; Pocket sciatica, Piriformis syndrome, Ultra

which underwent Electrotherapy (Ultra sonic Therapy

sonoic Therapy, Cross Fiber Friction, Positional Release

-US, Short wave Diathermy-SWD & Transcutaneous

January-June 2012

Electrical

International Journal of Rehabilitation Sciences (IJRS)

nerve

designed to increase the relaxation by mobilization of

Manual

surrounding muscle groups and joints, as well as to

Joint

increase the supporting strength of these muscle

Mobilization Techniques) and stretching exercises.

groups. In particular, the strengthening of the adductor

Both groups had MRI to rule out lumbosacral

muscles of the hip has been shown to be beneficial for

involvement in the radiating pain to the leg. All

patients with piriformis syndrome.22 Application of

subjects were taught about the awareness of habitual

deep transverse friction at tenoperiostial junctions is

pattern which may precipitate the symptoms of

helpful and should be focused on softening and

piriformis syndrome.

relaxing the piriformis and the other deep lateral

experimental Therapy

Stimulation-TENS)

group

which

management

The progress Oswestry

was

scale

(Soft

measured

(Appendix).

and

Volume I, Issue I

underwent Tissue

with To

modified check

rotators, as well as the gluteal muscles. 23

the

difference between means of the total disability score of the two groups, student t-test was used. A P<0.05

was

considered

statistically

significant. SPSS 17 was used for data analysis.

Results Total disability score at the start of the study and post test total disability score in experimental and control group are shown in figures 1, 2 and 3 respectively. Total disability post-test scores were lower in experimental group than control group (p=0.000007).

Discussion Most of the time in sports medicine regular stretching and manual therapy, like soft tissue mobilization approaches, tell a greater decrease and elimination of piriformis syndrome.18,19 Heat or cold therapy is usually most effectively applied before the physical therapy or home therapy sessions because it may decrease

the discomfort associated

with direct

treatment applied to an irritated or tense piriformis muscle.20, 21 Deep friction massage is also helpful for release of piriformis muscle with passive internal rotation of hip22. The ultimate goal of physical therapy is symptom elimination through a systematic program

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

11. Benzon HT, Katz JA, Benzon HA, Iqbal MS.

Conclusion The Soft Tissue and Joint Mobilization techniques along

with

stretching

exercises

provided

significantly better results as compared with Electrotherapy management in the patients with Piriformis Syndrom. They were safe and easy to perform.

5. 6.

Garyâ&#x20AC;&#x2122;s Anatomy, The Anatomical Basis of

8. 9.

literature.Anesthesiology.2003 12. DiGiovanna EL, Schiowitz S, Dowling DJ, eds. An Osteopathic Approach to Diagnosis and Treatment. 3rd ed. Philadelphia, Pa: Lippincott

management. Clin J Sport Med.2003; 21 14. Chaitow

L. Soft Tissue

Manipulation:

Piriformis

Practitioner's Guide to the Diagnosis and

Syndrome, Massage Today March, 2008, Vol.

Treatment of Soft-Tissue Dysfunction and

08, Issue 03

Reflex Activity. 3rd ed. 1988

Whitney Lowe, LMT, Treating

Dawson D, Hallett M, Wilbourn A. Entrapment

15. Peggi

Honig,

Treatment

Piriformis

Neuropathies, 3rd ed. Philadelphia: Lippincott-

Syndrome, Appling Modalities of Therapeutic

Raven, 1999.

Bodywork. Massage Manual. 2002

Travell J, Simons D. Myofascial Pain and

16. Schultz, Louis B., Feitis, Rosemary: The Endless

Dysfunction: The Trigger Point Manual, Volume

Web/Fascial Anatomy and Physical Reality.

2. Baltimore: Williams & Wilkins, 1992

North Atlantic Books 1996,

Klein, Milton J. Piriformis syndrome. eMedicine.

17. Douglas, Sara, Sciatic pain and piriformis

Nov 6, 2008. 14:2.

syndrome.. Vol. 22, The Nurse Practitioner, 05-

New injection technique. Anesthesiology. 2003

01-1997, pp 166(6).

Jun; 98 (6): 1442-8. PMID: 12766656. 7.

new injection technique, and a review of the

13. Prather H. Sacroiliac joint pain: practical

Clinical Practice, 40th edition 2008. 2.

Piriformis syndrome: anatomic considerations, a

Williams & Wilkins; 2005

Reference 1.

Volume I, Issue I

Benson

ER,

Schutzer

SF.

Posttraumatic

18. Hallin RP. Sciatic pain and the piriformis muscle. Postgrad Med 1983; 74:69-72.

piriformis syndrome: diagnosis and results of

19. Lori A. Boyajian-Oâ&#x20AC;&#x2122;Neill, Rance L. McClain,

operative treatment. J Bone Joint Surg (U.S.),

Michele K. Coleman and Pamela P. Thomas,

1999

Diagnosis

8. Magee D. Orthopedic Physical Assessment,

Syndrome:

3rd ed. Philadelphia: W.B. Saunders, 1997.

JAOA,108, November 2008 , 659-661

Wu, Q. Triple puncture with the bai hu yao tou

and

Management

Osteopathic

Piriformis Approach,

20. Beatty RA. The piriformis muscle syndrome: a

maneuver. J Tradit Chin Med. 2003. Sep: 23(3):

simple

197-8. PMID: 14535185.

1994; 34:512-514.

diagnostic

maneuver.

Neurosurgery.

10. Fishman LM, Anderson C, Rosner B. BOTOX

21. Fishman LM, Schaefer MP. The piriformis

and physical therapy in the treatment of

syndrome is under diagnosed. Muscle Nerve.

piriformis syndrome. Am J Phys Med Rehabil.

2003;28:646-649.

2002

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

Volume I, Issue I

22. Fishman LM, Dombi GW, Michaelsen C, Ringel S, Rozbruch J, Rosner B, et al. Piriformis syndrome: diagnosis, treatment, and outcomeâ&#x20AC;&#x201D;a 10-year study [review]. Arch Phys Med Rehabil. 2002; 83:295-301. 23. Arthur Hulbert, PT, DPT, and Gail D. Deyle PT, PhD. Differential Diagnosis and Conservative Treatment for Piriformis Syndrome: A Review of the Literature. In Current Orthopaedic Practice. May/June 2009. Vol. 20. No. 3. Pp. 313-319.

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

Volume I, Issue I

TRENDS AMONG THE PHYSICAL

language while 48.4% and 41.8% respectively

THERAPISTS ABOUT THE USE OF

definitely agree and agree somewhat for the need of

FUNCTIONAL STATUS ASSESSMENT TOOLS: A CROSS SECTIONAL

functional status and activity level assessment training in profession entry level courses. Conclusion: It is concluded that many physical

SURVEY

therapists recognize the importance of functional

Aut ho r s; M u ha m ma d Na wa z Mal i k

As h faq ,

Ar s had

status and activity level assessment but majority of them do not use any standard tools or measures for this purpose. There is obvious need to enhance the

Abstract Objective: The purpose of this study is to determine the current trends in functional status and activity level assessment in physical therapy clinical practice, to evaluate the extent of the use of standardized functional status and activity level assessment tools among Pakistani physical therapists, and to assess the

use of standard tools for which training and development of such tools in local languages with due considerations for socio-economic and cultural factors is also required. Keywords: Physical therapist, Functional status, Standard tools

need for the development of such tools in the Local

Introduction

National Language.

Assessment

Methods: The cross sectional survey was designed to

psychological,

conduct the study. Three hundred physical therapists

measurement of outcomes of rehabilitation process is

were included in the study from all over Pakistan.

Data for the study was collected through a structured

professionals and hence for physical therapists.(1)

questionnaire from the sample by means of purposive

Being responsible for functional training of patients/

sampling.

clients in self care and workplace the physical

Results: The results describe that only a few (10.9%)

therapists need to assess and analyze functional status

physical therapists use some standard tools for

comprehensively. (2,3)

functional status and activity level assessment, the

Various assessment tools for assessment of function

majority (51.4%) of Physical therapists use general

and activity level have been devised (Table I). The

observation for functional assessment, while the

use of such measures has been advocated and

remaining (37.7 %) neither use any tool nor general

emphasized for many decades by rehabilitation

observation for functional status and activity level

professionals, and organizations. The Guide to

assessment.

Physical

Physical therapists( 89.1%) who

currently are not using functional assessment tools/general observation showed their interest to use

significant

Functional social), problem

Therapist

Status

activity for

Practice

all

(physical, level

and

rehabilitation

recommends

that

expected outcomes be written in functional terms. (3,4,5)

such assessment tools in future and 57.5% of them

World Confederation of Physical Therapists (WCPT)

say that they need training for this. 95.4%

has emphasized the importance of functional status

respondents are definitely or agree somewhat for the

assessment through its inclusion in WCPT Guidelines

need of functional assessment tool in the

local

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

for Physical Therapist Professional Entry-Level Education, approved in 2007 and reviewed in 2011. (6)

Fig I No. of Participants (300)

Appendix A; Patient/Client Care/Management of

the

above

mentioned

guidelines

include

Volume I, Issue I

Complete Forms (58%) Incomplete Forms (1%) Not responded (41%)

the

Examination/ assessment/evaluation Functional status and activity level (current and prior functional status in self-care and home management including activities of daily living and instrumental activities of daily living with other components of patient/client care.

(3,6,9,11)

Results The results indicate that 10.9% physical therapists

Table I

use some standard tool for functional status and

Barthel index

activity level assessment

ICF: The World Health Organizationâ&#x20AC;&#x2122;s Classification of

therapists used general observation for functional

Functioning, Disability and Health (WHO-ICF) Model

assessment, while remaining 37.7% neither used any

Katz Index of Activities of Daily Living

tool nor general observation for functional status and

Functional Independence Measure (FIM)

activity level assessment. Hence collectively 89.1%

The Sickness Impact Profile

of the respondents did not use any standard tool for

The Outcome and Assessment Information Set (Oasis) The SF-36 Health Assessment Questionnaire Disability Index (HAQ)

Assessment Tools for Assessment of Function and Activity Level

and 51.4% physical

functional status and activity level (Fig II). 89.1 % physical therapists who did not use any functional assessment tools/general observation showed their interest to use such assessment tools in future and 57.5% of them said that they need training for this

Methodology

(Fig III). 95.4% respondent strongly agreed or agreed

A cross sectional survey was conducted at National

somewhat for the need of functional assessment tool

Institute of Rehabilitation Medicine Islamabad. The

in local language. 48% and 42% definitely agreed

Sample size was 300 physical therapists practicing in

and agreed respectively somewhat for the need of

Pakistan. Purposive sampling technique was used to

functional status and activity level assessment

collect the data. All physical therapist who are

training in profession entry level courses.

working in a clinical setting were included in the

Fig II

study and the physical therapists who are working in non clinical setting were excluded from the study. Survey questionnaire was administrated to 300 physical therapists in various regions of Pakistan; 175

Use of Assement Tool

Use Standard Tool (10.9%) Do not Use (37.1%)

respondents returned the complete questionnaires, three forms were incomplete and hence excluded. Remaining 122 physical therapists did not respond. (Fig; I)

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

Volume I, Issue I

outpatient clinics in the United States, Russek et al

Fig III

found that only 50% of the respondents used the

Training for Assessment Tools

Strongly agree (57.5%) Agree (37.9%)

outcome tools they had been provided by their

Not agree (4.6%)

physical therapists use outcome measures to record

clinics.

(13)

Much more disappointing results are

found in the this current study that only 10.9% functional status of their patients.(14) Attitudes and perceptions related to use of outcome

Fig IV

measures Training of assessment Tool at Entry Level Course Strongly agree (48.4%) Agree (41.8%)

among

other

health

care

providers,

including mental health practitioners, oncologists, general practitioners (GPs), and nurses, also have been reported. (15) The perceptions of the benefits of and barriers to

Not agree (9.8%)

using

standardized

outcome

measures

among

rehabilitation professionals have been evaluated in various studies and many of the reported barriers

Discussion Every

individual

values

the

ability

live

independently. Functional activities encompass all those tasks, activities and roles that identify a person as an independent adult or as a child progressing toward adult independence. These activities require the integration of both cognitive and affective abilities with motor skills. Functional activity is a patient referenced concept and dependent on what the

were similar across various studies. Perceptions about barriers include lack of time and inconvenience; lack of familiarity, know how, and training; and lack of resources such as staffing and automation.(16) The results of the present study also depict similar findings

language

difficulties,

subjective

information, lack of training, lack of timing and other supportive facilities

individual self identifies as essential to support

Conclusion

physical and psychological wellbeing as well as to

It is concluded that many physical therapists

create a personal sense of meaningful living. (2,7,10)

recognize the importance of functional status and

The need for physical therapists to use standardized

activity level assessment but majority of them do not

measures has been recognized at the national level in

use any standard tool or measures for this purpose.

the United States.(7,8) The Centers for Medicare &

There is obvious need to enhance the use of standard

Medicaid Services sponsored a report in 2006 to

tools for which there is need of training and

determine the possibility of a uniform rehabilitation

development of such tools in the local languages with

outcomes assessment method for patients leaving

due consideration for socio-economic and cultural

acute care. (Kramer AM, Holthaus D 2008). (12)

factors.

But various studies showed scarcity of use of standard assessment tools

for functional status and

activity level as in a study on physical therapists in

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

Volume I, Issue I

Recommendations;

Classification of Functioning, Disability and

It is recommended that the use of standard tool in

Health;Phy Th 2009

functional status and activity level assessment should

Mayo N, Cole B, Dowler J, et al. Use of outcome

be emphasized by educational institutions as well as

measurement in physiotherapy: survey of current

professional bodies. Further work is needed to

practice. Can J Rehab. 1993;7:81– 82.

develop a comprehensive tool for functional status

Kay TM, Myers AM, Huijbregts MPJ. How far

and activity level assessment in local languages with

have we come since 1992? a comparative survey

due considerations to socio-economic religious and

of physiotherapists’ use of outcome measures.

cultural factors. Training on functional status and

Physiother Can. Fall 2001:268–275.

activity level assessment and especially in using

Turner-Stokes L, Turner-Stokes T. The use of

standard tools may be added in professional entry

standardized outcome measures in rehabilitation

level courses, on job trainings, and as part of

centers in the UK. Clin Rehabil. 1997;11:306–

continuing education.

313. 9.

Haigh R, Tennant A, Biering-Sorensen F, et al.

References;

The use of outcome measures in physical

G Stucki and A Cieza; The International

medicine and rehabilitation within Europe. J

Classification of Functioning, Disability and

Rehabil Med. 2001;33: 273–278.

Health (ICF) Core Sets for rheumatoid arthritis:

10. Torenbeek M, Caulfield B, Garrett M, Van

a way to specify functioning Ann Rheum Dis

Harten W. Current use of outcome measures for

2004;63

stroke and low back pain rehabilitation in five

(Suppl

II)1140–1145.

doi:

10.1136/ard.2004.028233

European countries: first results of the ACROSS

O’ Sullivan Schmitz; Physical Rehabilitation,

project. Int J Rehabil Res. 2001;24:95–101.

Functional assessment Chapter 11, page 567-

11. Garland AF, Kruse M, Aarons GA. Clinicians

569. 5 ed

and outcome measurement: What’s the use? J

Diane U Jette, James Halbert, et.Al; Use of

Behav Health Serv Res. 2003;30:393–405.

standardized outcome measures in Physical

12. Meadows KA, Rogers D, Greene T. Attitudes to

therapist Practice; perceptions and applications;

the use of health outcome questionnaires in the

physical. ther. 2009; 89:125-135

routine care of patients with diabetes: a survey of

WCPT

Guidelines

for

Physical

Therapist

Professional Entry-Level Education; Approved At The 16th General Meeting Of WCPT June 5.

general practitioners and practice nurses. Br J Gen Pract. 1998;48:1555–1559. 13. Christine Collin; Measurement of Disability and

2007 And Reviewed 2011

Handicap;

Sean D Rundell, Todd E Davenport, Tracey

Rehabilitation

Handbook

Neurological

Wagner: Physical Therapist Management of

14. Kathryn M.Sibley, Sharon E. Straus, Elizabeth

Acute and Chronic Low Back Pain Using the

L. Inness et al; Balance Assessment Practices

World

and Use of Standardized Balance Measures

Health

Organization’s

International

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

Volume I, Issue I

among Ontario Physical Therapists; Physical therapy 2011. 15. Hatfield DR, Ogles BM. Why some clinicians use outcomes measures and others do not. Adm Policy Ment Health Ment Health Serv Res. 2007;34:283–291. 16. Mahoney FI, Barthel D. “Functional evaluation: the Barthel Index.” Maryland State Medical Journal 1965;14:56-61. Used with permission.

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

THE PREVALENCE OF CHRONIC

characters

LOW BACK PAIN IN OFFICE

performance during job. By improving the LBP job

does

affect

the

Introduction

GHURKI TRUST TEACHING

Chronic low back pain is one of the major causes of

HOSPITAL, LAHORE Authors: Hafiz Muhammad Asim, Muhammad Shahid Ismail

patients coming in Hospital & clinical setup. Despite of accessibility to highly sophisticated diagnostic tools, it seems difficult to find out the exact cause of

Abstract

chronic low back pain. Mechanical back pain is

Objective: To find the prevalence of chronic low back pain among LMDC & GTTH office workers and effect of low back pain on their job performance and satisfaction. this study with the help of convenience sampling techniques. 59 of them were male and remaining 34 were female. A cross sectional survey was done. Participants of the study are of both genders and of any age having established diagnosis of chronic low back pain. Duration of the study was 3 months. Pain intensities were found associated with poor habit of sitting during their job hours. 82% of participants were not involved in exercise habit. Only 23.7% of them used adjustable back support. Sleep disturbance was present among candidates. Almost 50% of them had a sleep disturbance episode once or twice a week. candidates

complained

poor

job

performance.

lack of awareness people often exploit their posture them do not have awareness of whether their posture was faulty or good, others ignore considering this. Chronic low back pain may be caused by many diverse origins. It may start from diseases, injuries or stresses to many different structures including bones, muscles, ligaments, joints, nerves or the spinal cord. nerve endings, up the spinal cord and into the brain where it registers as pain. Several times, the exact source of the pain is not well clear at the end of assessment.

(1)

Psychological factors are even more

imperative in patients with chronic back pain. Disappointment with a work situation, a director, or a blind alley job and tedium contribute greatly to the commencement and persistence of back pain. Disc herniation and spinal canal narrowing are so frequent

Conclusion; This survey indicates the prevalence of low back pain in the office workers of Ghurki Trust Teaching Hospital Lahore. The workers need postural reeducation to prevent the low back pain.

Re-

education could decrease the cost on treatment but satisfaction,

focus of treatment. Due to low level of literacy and

The affected structure will send a signal through

Results: Out of 93 participants, 63% were males.

will

broad, most frequently encountered and most widely

during ADL, IADL and sport activities. Some of

Methodology: Ninety three workers were enrolled in

may

LBP

Key words: Chronic back pain, Posture.

AND DENTAL COLLEGE AND

patients.

performance can be increased.

WORKERS OF LAHORE MEDICAL

53%

Volume I, Issue I

increase job

the

quality

functional

level,

and

ergonomic

other

job

as to be shown by MRI imaging in a large amount of the people in their later years, and in most cases, such conditions are not responsible for the pain. They are often referred to as reasons for surgery, but only seldom are operations successful in improving the pain definitively. (2)

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

Volume I, Issue I

the comfort of being and reduce the risk of back pain.

Literature Review O'Sullivan PB, Smith AJ, Beales DJ, et al in 2011

(11.12)

. Their findings indicate that sitting with an

found a drop in the association between sitting

increased lower lumbar support result in a reduction

posture and self-reported back pain. The purpose of

of the load at the lumbar spine and lumbar muscle

this study was to determine whether the degree of fall

activity, which may be related to potentially reduce

in the session was associated with sex and physical

back pain (13).

lifestyle or psychosocial factors (2, 3)

An O Sanya and F O Omokhodion studied back pain

A large epidemiological study on low back pain in

in office workers in Nigeria. The aim of this study

the general population in the Netherlands was

was to determine the prevalence and risk factors for

conducted between 1993 and 1995. The study

back pain among office workers in Ibadan, Nigeria.

population consisted of a sample of 13,927 men and

The severity of back pain was found associated with

women aged 20-59. Almost half of respondents

sitting for more than 3 hours. (15)

(49.2% including 45.5% of men and women 52.4%)

Panagiotis Spyropoulos, PhD, George Papathanasiou,

reported back pain in the previous year. Over 40% of

MSc, Georgoudis George, PhD, et al found the

respondents indicated that the episode lasted more

prevalence of LBP in the Greek civil service workers.

than 12 weeks (7.1%) or low back pain was

The study was a cross sectional survey. They found

continuously present (34.7%). Chronic back pain is

that a high proportion of Greek office workers suffer

more common in women (22.6%) than men (18.3%)

from back pain that may affect the Greek economy.

and increases with age from 12% to 27.1% in 20-29

The incidence of low back pain condition was

years and 50-59 years. (3)

significantly

The occurrence of back pain was significantly higher among women than men. About 46% of women complained of back pain compared with 34% of men. Back pain is caused by fatigue (39%) or general physical weakness (28%), while 10% concerned were due to the uncomfortable bed and 9% due to wrong posture in daily activities.

(3, 4, 5)

Posture of patients

with postural back pain was assessed by Lauren Womersley, and Stephen May on July 15, 2005. The group with backache sat for longer periods without interruption and had a more relaxed sitting position in flexion than without back pain group. (6,7,12) Effects of sitting with adjustable back support on sciatica and low back pain at work were found by Mohsen Makhsous, Fang Lin, James Bankard, et al.(8) They argued that reduced load on the spine and the activities of the low back muscles, can help increase

associated

with

some

anthropometric factors, and ergonomic.

the

(14,15)

Methodology A cross sectional study was completed in 3 months from January 1, 2012 to March 28, 2012 conducted at Ghurki Trust Teaching Hospital Lahore Medical and College, Lahore. A sample of 93 workers was taken. The history of posture during job & work and their effect on their performance was taken through a structured questionnaire.VAS (Visual Analog Scale) for pain intensity & pain duration were two dependent variables in study. It constituted as the blue print of collection, viewing observations, analysis of records. Direct personal method was used in this study; the researcher approached the workers and interviewed them. Multiple bar charts were used to present two or more categorical variables.

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

Volume I, Issue I

Results

cure this problem. This survey emphasizes the need

Ninety three patients were enrolled in this study with

of postural reeducation. Significance of forward

the help of convenience sampling technique. There

bending during sitting could not be evaluated. Further

were 59 male and remaining 34 were female. Pain

studies are required in this context. Among the

intensities were found associated with poor habit of

individual risk factors, gender is also an important

sitting during their job hours. (Figure I) 82% of

risk factor. Females are showing more intense pain.

participants were not involved in exercise habit. Only

This may be because of their psychological factor.

23.7% used an adjustable back support. (Figure II)

Only middle and lower class are targeted because of

Sleep disturbance was present among candidates.

limited sources. But this can be correlated with the

Almost half of them had it once or twice per week.

fact that 98% population of Pakistan comprise of

55%

middle & lower class (28% & 70% respectively).

candidates

complained

poor

job

performance. (Table I)

Awareness about exercise habit is very important.

Figure I Job Performance

Proper awareness program about correct sitting posture and habit should be done using community,

office and other job based programs. A Performa

about recommendations of correct sitting posture is

40 30

Good

Poor

distributed among patients for their proper education. Most of patients ignore their pain status. Education about proper time management and cure of it should be emphasized.

It could decrease the cost on treatment but also will increase the functional level, job satisfaction, job quality and other ergonomic characters of patients.

Figure II Adjustable Back Support

Back support chairs maintain the stability of pelvis

100

and spine but render spine straightening. People are

not properly educated to use correct posture during

60 40

Yes NO

20 0

their job. Some community based education and awareness programs must be run for posture guidance. Adjustable back support maintains the alignment of spine on pelvis. Height of seat is very crucial. It is variable according to the height of candidate. Adjustable seating surface make it

Discussion

possible to adjust according to different structured

In a country like Pakistan, where 70% of population

candidates. Sleep disturbance ultimately increases

belong to lower class so high expenses on the

pain and tension. By decreasing the LBP work

treatment of lower back pain are not affordable. A

performance can be enhanced.

general awareness program on correct postural can

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

Volume I, Issue I

Table I Study sample No.

The intensity of LBP %age

Unbearable

Severe

No.

%age

No.

%age

Moderate

Mild

Discomfort

No.

%age

No.

%age

No.

%age

Gender Male

63.4

Female

36.6

Age group (years) ≤34

55.9

≥35

44.1

Exercising habit Yes

18.3

81.7

Conclusion

efficacy of physical therapy and physical

According to the results posture awareness is very

modalities for control of chronic musculoskeletal

poor in office workers of Ghurki Trust Teaching Hospital Lahore. They often use poor posture while

pain, Pain 71 (1997), pp. 5–23 5.

they are sitting. And they do not even recognize it. problems but also causes increased expenses on their

1999;1765- 69 6.

treatment and also affects their job activities. This affects

their

job

performance

trials. Arch Intern Med. 1998;1582235- 2241 7.

Kendall, F.P., McCreary, E.K., & Provanc, P.G. (1993). Muscles, testing and function (4th ed). Baltimore, MD: Williams & Wilkins.

Hochberg

MC. Back

pain

exacerbations and lost productive time costs in United States workers. Spine 2006;31 (26) 3052-

therapy for the treatment of chronic discogenic 10:271–81.

and

Ricci JA, Stewart WF, Chee E, Leotta C, Foley

Saal JA, Saal JS. Intradiscal electrothermal low back pain. Operative Tech Orthop 2000;

disabilities

1572

120919-4 2.

United States, 1999. JAMA 2001;285 (12) 1571-

Start of the New Millennium. Report of a WHO Report Series, 919, 2003, pp. 218. ISBN: 92-4-

Prevalence

associated health conditions among adults—

The Burden of Musculoskeletal Conditions at the Scientific Group. Geneva: WHO Technical

From the Centers for Disease Control and Prevention,

References 1.

Ernst E, White AR. Acupuncture for low back pain: a meta-analysis of randomized controlled

and

satisfaction.

Ernst E. Massage therapy for low back pain: a systematic review. J Pain Symptom Manage.

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J Feine and J Lung, An assessment of the

3060 9.

Fairbank J C T, Park W M, McCall I W, O'Brien J P. Apophyseal injection of local anesthetic as a diagnostic

aid

primary

low-back

pain

syndromes. Spine 1981; 6:598-605.

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

Volume I, Issue I

10. O'Sullivan PB, Smith AJ, Beales DJ, Straker LM, Association of biopsychosocial factors with degree of slump in sitting posture and self-report of back pain in adolescents: a cross-sectional study, 2011 Apr;91(4):470-83. 11. Lauren Womersley, Msca, Stephen May, Bscb, Sitting Posture Of Subjects With Postural Backache,

Journal

Manipulative

And

Physiological Therapeutics 2006, Volume 29, Issue 3, Pages 213-218 12. Raymond J, Dumas J. Intraarticular facet block: diagnostic

test

therapeutic

procedure?

Radiology 1984; 151:333-6. 13. Lippitt A B. The facet joint and its role in spine pain. Management with facet joint injections. Spine 1984; 9: 746-50. 14. Lau L S, Littlejohn G 0, Miller M H. Clinical evaluation of intra-articular injections for lumbar facet joint pain. MedJAust 1985; 143: 563-5. 15. Lewinnek G E, Warfield C A. Facet joint degeneration as a cause of low back pain. Clin Orthop 1986; 213: 216-22.

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

THE EFFECTIVENESS OF SUSTAINED STRETCHING IN POST STROKE UPPER LIMB SPASTICITY

Volume I, Issue I

Key Words: Stroke, Spasticity, Upper Motor Neuron Syndrome (UMNS), sustained stretching (SS), Range of motion (ROM) and Modified Ashworth Scale (MAS), CVA, MCA syndrome.

Authors; Shaukat Ali, Muhammad Farrukh Shahzad

Introduction

Abstract

Spasticity, a type of hyper tonicity is an increase in

Objective: To establish the effectiveness of sustained

muscle tone owing to the hyperexcitability of the

stretching in reduction of post stroke upper limb

stretch reflex and is characterized by a velocity-

spasticity.

dependent increase in tonic stretch reflexes.

Methods: A case series of 8 weeks duration with 5

Spasticity usually accompanies paresis and other

sample size was conducted on home based patients in

signs, such as increased deep tendon reflexes,

Islamabad and Rawalpindi. Case series describing

collectively called the upper motor neuron syndrome,

the outcomes of individual patients with spasticity

UMNS. Paresis particularly affects distal muscles,

were treated with sustained stretching. The post-

with inability to perform isolated movements of the

treatment effectiveness of stretching protocol was

digits. The upper motor neuron syndrome results

assessed by reference to the pre-treatment Modified

from an insult to descending motor pathways at

Ashworth Scale (MAS), passive range of motion

cortical, brainstem, or spinal cord levels, and

(ROM) on fortnightly basis.

Five stroke patients

spasticity develops gradually in days and weeks after

aged between 45 and 65 years with spasticity were

injury. In acute phase of upper motor neuron

included in this case series. All patients were treated

syndrome, muscle tone is flaccid with hyporeflexia

with sustained stretching from 1 to 2 minutes, 12

before the appearance of spasticity. The interval

times per session four times a week to minimize

between injury and the appearance of spasticity

spasticity.

varies from days to months according to the level of

Results: It was observed that spasticity decreased in

the lesion. In addition to weakness and increased

two out of five cases with fair improvement on

muscle tone, the signs in upper motor neuron

Modified Ashworth Scale (MAS), passive range of

syndrome

motion (ROM).Two out of 5 patients improved with

phenomenon, hyperreflexia, the Babinski sign, flexor

MAS score from 2 to +1. While only one patient

reflexes, and flexor spasms. Spasticity is measured on

showed improvement in passive ROM.

a scale called Modified Asworth Scale.

Conclusion: The findings of this study suggest that

Stretching, the process of elongation, is one of the

sustained stretching plays a little role in reduction of

currently

include

used

clonus,

techniques

the

(1)

clasp-knife

the

physical

spasticity in terms of improvement in range of

management of spasticity

motion (ROM) and improvement on Modified

Stretches (i.e., with a dynamometer or an intelligent

Ashworth Scale (MAS). Although, there were certain

feedback-controlled device) offer well controlled

limitations because of small sample size however,

interventions. Manual stretching is more difficult to

further research is needed such as RCTs to generalize

standardize but suits clinical practice better. During

(2, 3)

. Mechanically applied

the results.

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

stretching, tension is applied to soft-tissue structures (4)

. They are muscle, tendon, vascular, dermal, and

neural tissues

(2).

Volume I, Issue I

Methods Stroke patients of case series study were seen and

It is important to know that a

given therapy at their homes in Islamabad and

particular stretching exercise can apply tension to

Rawalpindi. The time span of the study consisted of

different structures in different people, especially in

two months i.e. from February 2011 to April 2011.

patients with deformities. Stretching may change the

Convenient sampling method was used in selecting

muscleâ&#x20AC;&#x2122;s viscoelastic, structural, and excitability

five

properties.

(3)

stroke

patients

having

inclusive

criteria

However, many neural and nonneural

characteristics. Stroke patients, male and female

responses to stretch, especially in spasticity are yet to

aged between 45 and 65 years, who had had stroke

be clearly understood. The aims of stretching in

attack at least 3 months before the start of the study,

spasticity may be to normalize muscle tone, to

taking

maintain or increase soft-tissue extensibility, to

concerned

with

their

conditions,

were

included in the study. Selected

reduce pain and to improve function.

(3)

Stretching

no medications except those drugs merely morbid

and

comorbid

programs for people with spasticity are usually used

stroke patients had not been involved in any

as a daily or weekly regimen over a long-term

stretching program before this

placing large demands on resources. Stretching as a

patients, male and female having ages below 45 and

treatment can vary in a large number of ways. The

above 65 years were not included in the study.

intensity of the stretch is the amount of tension that is

(Young stroke, a stroke in which patient age is below

applied to the structure(s), which not only can be

45 years). Patients taking anti spasmodic or other

different in force level but can also be kept either

medications of the same action even matching the

constant or can be varied. The velocity of the stretch

age inclusion criteria were not included in the study.

is the speed at which the elongation is occurring.

An assessment form was used for subjective data.

Repetitions are the number of replications of the

Modified Ashworth Scale (MAS) was used as an

stretch within 1 session.

(4)

assessment tool for spasticity and reassessment tool

Static, dynamic, prolonged, and ballistic stretching

for reduction in spasticity.

are used in the stretching literature. In static

Figure 1

(sustained) stretching, there is usually only 1

20 15 10 5 0

repetition, whereas in dynamic stretching there are more than 1 repetition. The duration is the period the structures are elongated within 1 repetition. The dose

study. Stroke

MAS time of stroke

can be considered to be the total end range time; in other words, the total time structures are elongated. The frequency is the periodicity of the stretch, which

Patientâ&#x20AC;&#x2122;s data at the start of the study

can vary from a single session to daily sessions for several weeks.

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

Volume I, Issue I

modified Ashworth Scale and improvement in

Figure 2

4 3 2 1 0

2nd week (MAS)

passive ROM.

4th week(MAS)

female) showed fairly improvement in their spasticity

Out of five patients, two patients (one male and one

6th week(MAS)

with sustained stretching. It was observed that sustained stretching has a little role in reduction of upper limb spasticity in stroke patients.

Patients’ spasticity data measured on fortnightly basis

Discussion The results of this study showed that sustained stretching can hardly reduce upper limb spasticity in stroke patients. All the cases were of ischemic left CVA. (MCA syndrome). Sustained stretching has a very little role in reduction of spasticity in stroke

terms of reduction in spasticity on Modified Ashworth Scale (MAS). The patient spasticity was measured on fortnightly basis. At the end of the 2nd week no improvement was observed in patient’s spasticity, at the end of the 4th week patient spasticity did not show any change, at the end of the 6th week patient’s spasticity was found to be reduced when

patients. In this case series total five cases were included in which two patients were female and three male. The patients’ average age was 54.6 years. The male patients’ average age was 52 years while female During this study sustained stretching was applied to five stroke patients with mild to severe upper limb spasticity. Every patient was treated for two months

further changes were observed in the spasticity of this patient. This case showed the effect of sustained stretching in reduction of spasticity. This case study Flexor and Extensor Spasticity Following Muscle Stretch”

AL-ZAMIL

Rehabilitation

Department, College of Medical Applied Sciences, King Saud University, Riyadh, Saudi Arabia , N.

(8 weeks) at his/her home. In five cases, one case was mild, with mild spasticity, one was severe with severe spasticity and the remaining three cases were of moderate nature, with

Hassan,

Rehabilitation Department, College of

Medical Applied Sciences, King Saud University, Riyadh, Saudi Arabia and W. Hassan, Rehabilitation Department, College of Medical Applied Sciences,

moderate spasticity. Modified Ashworth Scale (MAS) was used for reassessment

reassessed on MAS. At the end of this study no

is supported by a study on “Reduction of Elbow

patients’ average age was 58.5 years.

assessment,

Case-1: The results of this case were analyzed in

and

reevaluation

spasticity. (5) Two out of three moderate cases showed improvement on Modified Ashworth Scale (MAS). One case did not show any improvement on MAS. Improvement in passive ROM was noted in one of the moderate cases which also showed improvement on Modified Ashworth Scale. Both the severe and mild cases failed to show any improvement on

King Saud University, Riyadh, Saudi Arabia. The study concluded that by using sustained stretching of the spastic muscles one or several times a day, spasticity can be diminished to a level to facilitate voluntary movement and improve EMG profiles during voluntary movement. (5). Case-2: The results of this case were analyzed in terms of reduction in spasticity on Modified Ashworth Scale (MAS). The patient’s spasticity was

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

Volume I, Issue I

measured on fortnightly basis. At the end of the 2nd

prevention of contractures. The review included

week no improvement was observed in patient

randomized controlled trials and controlled clinical

spasticity, at the end of the 4

week patient’s

trials of stretch applied for the purposes of treating or

spasticity was found to be reduced when reassessed

preventing contractures in people with neurological

on MAS, at the end of the 6 week patient spasticity

conditions. The study concluded that regular stretch

did not show any changes. At the end of this study no

produces negligible clinically important changes in

further changes were observed in the spasticity of this

joint mobility, pain, spasticity, or activity limitation

patient. This case showed the effect of sustained

in people with neurological conditions. (6)

stretching in the reduction of spasticity. This case

In a nutshell the result of this study showed that

study is supported by a study on

“Reduction of

sustained stretching can hardly reduce upper limb

Elbow Flexor and Extensor Spasticity Following

spasticity in stroke patients. Sustained stretching has

Muscle Stretch” by Z.M. AL-Zamil, Rehabilitation

a very little role in reduction of spasticity in stroke

Department, College of Medical Applied Sciences,

patients.

King Saud University, Riyadh, Saudi Arabia , N. Hassan,

Rehabilitation Department, College of

Medical Applied Sciences, King Saud University, Riyadh, Saudi Arabia and W. Hassan, Rehabilitation Department, College of Medical Applied Sciences, King Saud University, Riyadh, Saudi Arabia. The study concluded that by using sustained stretching of the spastic muscles one or several times a day, spasticity can be diminished to a level to facilitate voluntary movement and improve EMG profiles

Conclusion After the completion of this research study it is concluded that sustained stretching plays a little role in the management of spasticity. During this case series all the five cases were treated with sustained stretching and got inconclusive results. The results of this study are also supported by a number of other research studies. Although, there were certain limitations because of small sample size however, further research is needed such as RCTs to generalize

during voluntary movement. (6) Case-3, 4 and 5: The results of these cases were analyzed in terms of reduction in spasticity on Modified Ashworth Scale (MAS). The patients’ spasticity was measured on fortnightly basis. During

the results

References 1.

RG, Yound RR, and Koella WP, eds. Spasticity:

the two month course of these cases no change had

Disordered Motor Control. Chicago: Year Book

been observed in the spasticity of patient with sustained stretching. This case is supported by a study on “Effectiveness of Stretch for the Treatment

Medical; 1980:485-494. 2.

treatment of spastic hypertonia. Phys Med

Owen M. Katalinic,

Lisa A. Harvey and Robert D. Herbert. The purpose of this systematic review was to determine the effectiveness of stretch for the treatment and

Gracies JM. Pathophysiology of impairment in patients with spasticity and use of stretch as a

and Prevention of Contractures in People With Neurological Conditions” by

Lance JW. Symposium synopsis. In: Feldman

Rehabil Clin N Am 2001; 12:747-68, VI. 3.

Stokes M. Physical management of neurological rehabilitation. 2nd ed. London: Elsevier Mosby; 2004.

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

Volume I, Issue I

Harvey L, Herbert R, Crosbie J. Does stretching induce lasting increases in joint ROM? A systematic review. Physiother Res Int 2002; 7:113.

AL-Zamil, Z. M., Hassan, N., & Hassan, W. (1995

September)

Reduction

Elbow

flexor and Extensor Spasticity Following Muscle Stretch. 9 (3), 161-165. 6.

Owen M. Katalinic, Lisa A. Harvey and Robert D. Herbert, physiotherapy, Effectiveness of Stretch for the Treatment and Prevention of Contractures

in People

With Neurological

Conditions: A Systematic Review. PHYS THER. 2011; 91:11-24.

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

Volume I, Issue I

THE ROLE OF STRETCHING

(CAS) from an average of 14/16 to 10/16. After a

EXERCISES IN RELIEVING

month, subject achieved a Modified Ashworth Scale (MAS) 1/4 and Constipation Assessment Scale

CONSTIPATION IN THE SPASTIC

(CAS) 5/16. These results were maintained at a long-

CEREBRAL PALSY

term follow-up performed with treatment.

Authors; Farkhanda Shaheen, Waqar ahmed Awan

Conclusion: stretching exercises were effective as for both spasticity and constipation in spastic cerebral

Abstract Objectives: To examine the effect of stretching exercises for the improvement of constipation in spastic cerebral palsy patient. Methods and Measures: A seven year’s old child with spastic quardriplegia due to cerebral palsy referred to physical therapy department of armed

palsy. The results of this study suggest that stretching may be helpful in constipation. Additional advanced studies should be conducted to confirm the effect of stretching in constipation in spastic cerebral palsy. Keywords: Stretching Exercises, Spastic Cerebral Palsy, Constipation

Forces Institute of rehabilitation medicine for the

Introduction

management of the cerebral palsy. During evaluation

Cerebral palsy (CP) is a nonprogressive condition. It

the therapist found that child was also the patient of

manifests

chronic constipation. For constipation patient was

musculoskeletal system due to early developmental

treated with enema before the stretching exercises.

disorders of the central nervous system.(1, 2)

The subject was treated daily at physiotherapy

Recent studies showed that the incidence of CP is

department with stretching exercises, home stretching

2.5/1000 live births.(2) In children with chronic

exercises program was also given to perform three

disabilities due to neurodevelopmental disorders like

times a day along with reflex inhibiting posture after

cerebral palsy, gastrointestinal system impairments

the stretching exercises. Stretching of the calves,

are common depending on the severity of the

hamstrings, illiopsos, adductors of hip and trunk

disorder.(1, 3, 4)

rotator were performed. Modified Ashworth Scale

Constipation is one of the most frequent problems in

was used to determine the level of spasticity. In

CP. The reasons for constipation in cerebral palsy are

addition,

was

insufficient nutrition, malnutrition, increased muscle

administered to the subject to determine the severity

tone, decreased defecation, and immobilization. It

of constipation. The satisfaction from the treatment

may worsen with the increase in severity of the

was measured using modified Ashworth scale,

disorder, in the presence of mental retardation, and

Constipation Assessment Scale and parent’s feedback

due to decrease in physical activity level.(3, 5, 6)

about the behavior and attitude of child after

Various studies indicate that the percentage of

treatment.

constipation is much greater in children with

Results: After the first week of the treatment, the

intellectual and neurologic problems, than healthy

stretching exercises decreased the spasticity on

ones.(2, 3, 7, 8) In a study, Giudice et al1 found that in

Modified Ashworth Scale (MAS) from 3/4 to 2/4 and

children

Constipation

Assessment

Scale

itself

with

CP,

various

the

impairments

percentage

that

had

improved subject’s Constipation Assessment Scale

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

Volume I, Issue I

constipation was 74%. In healthy children with

for the management of spasticity in both upper and

regular intestinal movements, evacuation of feces is

lower limbs. The patient’s mother also reported a six

(9, 10)

years history of chronic constipation. The subject

However, as stated by Park et al(11) and Staiano and

also had fits and took medicine to control the fits and

usually achieved three or four times per week. Del Giudice,

(12)

children with CP have lower

spasticity (Primidone-Barbiturate). The subject’s

frequency of defecation (one per week or 01/10 days)

mother described the child’s constant constipation

and longer colonic transit passage compared with

that varied, depending on spasticity control and fits

healthy children.

control medication. She denied any rehabilitation

As well as the CP children with bowel and bladder

exercises/ physical therapy management at the time

problems and abdominal pain also negatively affect

of subjective and objective examination.

(2, 4, 13)

the families and causing anxiety.

In turn,

As a spastic CP the subject’s activity was completely

combined with other problems, constipation may lead

restricted to bed. The child’s current constipation and

to a decreased quality of life of children and their

spasticity aggravated with immobility and lack of

(4, 13, 14)

families.

Along with laxative drug regimens

exercises. Once constipation aggravated the child

and diets including fibrous food, there are also some

physician was attempting to manage with laxative

alternative approaches in trial for the treatment of

medication and enema after every two weeks.

constipation. Relevant tonus and tissue texture

Because of constipation there was abdominal

changes are carefully investigated to understand the

distension and reduced decreased bowel movement.

cause of restrictions and alterations in normal

Along with bowel movement child became distressed

movement. To attain the improvement in the

and unable to pass stool. There was also very low

constipation, we applied stretches, mobilizations and

dietary

manipulations to the musculoskeletal and visceral

constipation. Actual presence of constipation was due

systems. For

(15, 16, 17)

constipation,

intake

which

further

increased

the

to spasticity of sphincter muscle, illiopsos, and are

adductor of hip, inactivity and fits control medication

hypothesized to be effective because peritoneal

also induced constipation. There was also increase in

structures surrounding the viscera may have lost their

generalized tone which also increased the colonic

normal resilience. The goal of stretching exercises is

transit time. Previous treatment of constipation only

consisted of laxative medication and enema. Enema

restore

the

range

stretching

exercises

movement

abdominal, pelvis and thigh muscle tone.

decrease (15, 17)

This

was given mostly after two weeks which was slightly

relatively case report pilot study was designed to

helpful to pass stool but in small volume.

describe potential effects of stretching exercises on

Test and Measure; Assessments were conducted

constipation in children with CP.

before and after intervention, in one month. The

Methods History of Case: A seven year’s old CP quadriplegic male child referred to Physical therapy department of

following tools were used as outcome measures: defecation frequency (times/wk), Modified Ashworth Scale (MAS),

(17)

Constipation Assessment Scale

(CAS), (18, 19)

Armed Forces Institute of Rehabilitation Medicine

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

Volume I, Issue I

Modified Ashworth Scale. Modified Ashworth Scale

Intervention; The subject received 40 physical

is a subjective measurement tool used to assess the

therapy sessions over a two month period. Stretching

level of spasticity within a range of 0 (no increase in

exercises and reflex inhibiting posture were used to

muscle tone) to 5 (normal joint movement is totally

manage the spasticity and constipation.

restricted).

(17)

Modified Ashworth Scale values were

Table 1 provides a summary of each treatment

calculated for the hip flexors, adductors, internal

session, and post-treatment results.

rotators, knee flexors, and ankle plantar-flexors in the

Stretching exercises were initially targeted at hip

lower extremities and shoulder flexors, adductors,

adductors, illiopsos, quardratus lumborum and trunk

internal rotators, elbow flexors, hand flexors, and

rotators. As treatment progressed, Hamstrings and

finger flexors in the upper extremities. Then, a total

calve muscles in lower extremity, shoulder flexor,

spasticity value was calculated by summing these

adductor, internal rotators, elbow and wrist flexor

separate MAS scores to determine a spasticity level

were also assessed and treated.

for the whole body.

During the stretching exercises the intensity of Constipation

stretching was managed by the visual analog scale.

Assessment Scale is a valid and reliable tool

The initial treatment session was started with subject

consisting of 8 self-reported items investigating the

in supine on bobath bed. Stretching started from

presence and severity of constipation in both children

proximal to distal muscles. While maintained the

Constipation

and adults.

Assessment

(18)

Scale.

The scoring is provided by a 3-point

reflex inhibiting posture of hip in abduction and in

rating scale indicating 0 as no constipation, 1 as some

knee extension. Each stretching was maintained for

problem, and 2 as severe problem. Total score ranges

one minute and repeated for ten times on each group

between 0 (no constipation)

and 16 (severe

of muscle. Along with stretching of the extremityâ&#x20AC;&#x2122;s

constipation). Although CAS is a self-reported

muscles, muscle of the lower back and abdominal

questionnaire, parents or caregivers were asked to

muscle were also focused. After these stretching

answer the questions for those children who were

exercises, patient was kept in weight bearing position

unable to read and/or comprehend the scale because

in sitting to improve balance and stretching of tight

of their age.

(18)

calve.

Diagnosis: Based on the findings from the physical

Following the stretching session, the spasticity

exam, primary study hypothesis was that constipation

slightly reduced. A home exercise program was

is related to spasticity in the cerebral palsy.

taught to the mother of the subject. This included

Spasticity

produced

stretching of the illiopsos, hip adductors, hamstrings

constipation. It is unlikely that stretching exercises

and calves in lower extremity, shoulder flexor,

and reflex inhibitory posture would have immediate

adductor internal rotators, elbow and wrist flexor in

effect on constipation. The subject had pelvic floor

upper extremity and also lumbar side flexors and

muscles tightness and immobility which is possible

trunk rotators. Each stretching was performed two

source of constipation. A good prognosis was based

times a day. After each season at home position of

on the childâ&#x20AC;&#x2122;s decreased constipation following the

the limb was kept in reflex inhibiting posture.

along

with

immobility

stretching exercises of tight muscles.

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

Home exercise program was provided to and continued to focus on stretching that replicated and

Table II Result’s Summery Session

reinforced clinic treatments. (Table I) Intervention Stretching

Focused Muscles 

Exercises 

CAS 14 (Severest

movement is difficult)

Constipation)

2 (More marked increase in

10 (Severe

muscle tone, passive

Constipation)

Day 20

In lower Extremity; Adductor of Hip,

movement is easy)

Illio Psos, Hamstrings, TA.

1+ (Slight increase in muscle

8 (Moderate

Abdominal and Lower Back Muscles

tone, manifested by a catch,

constipation)

(External Oblique, Internal Oblique, Quardratus Lumborum. 

MAS for Spasticity 3 (marked spasticity, Passive

Day 10

Table I Summery of Interventions

Volume I, Issue I

Upper

Extremity;

followed Day 30

Adductor

As Above

Program



Reflex Inhibiting Posture

the

the ROM)

and Wrist. 

minimal

throughout

remainder (less than half) of

Shoulder, Flexor Of Shoulder, Elbow Home Exercises

resistance

Day 40

1 (Slight increase in muscle

5 (Mild

tone, manifested by minimal

constipation)

resistance at the end range of motion when the part is moved

Results

flexion

extension/abduction

The spasticity of the muscle was at scale 3 of MAS

or or

adduction)

for spasticity at the time of management started to 10th session. The child’s constipation was most severe scoring 14/16 on CAS and he was unable to pass stool until enema was provided which was after every 2 weeks. After child’s last session MAS for spasticity was reduced to 1 in which there was

Discussion The etiology of constipation depends on a complex neural control system between brain gut axis encompassing

the

interaction

biologic,

psychosocial, and early life factors related to the

slightly increased muscle tone and CAS was also

development of constipation. (6,13,20) In patients with

reduced to 5 in which small volume of stool was

neurologic involvement, the deregulation of the

passed one time a week without enema or laxative drugs. Before management frequency of stool pass

central nervous system, altered intestinal motility, and increased visceral sensitivity cause a disruption

was once after 2 weeks with the help of enema or

of this axis.(21) In addition, the normal passive

laxatives. Improvement in the constipation also

movement of the visceral organs is hampered because

improved the child’s intake of diet and fluid. It was also noticed that the child became calm and relax after

reduced

spasticity

and

constipation.

subsequent follow-ups performed after every three days for the rehabilitation of CP, it was noticed if the child got fever his spasticity and constipation were also aggravated. So the child’s parent was taught to take care this issue. (Table II)

of restrictions and limitation of body movements. In this study, the aim was to achieve the regulation of this pathological condition providing normal mobility in all joints and muscle with the help of stretching exercises. Parallel to the developments in alternative medicine, physical therapy has become a frequently used method in the clinic, although there are limited

January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

studies related to the field. Moreover, there are fewer

RCT

studies concerning the effects of manual therapy

mobilization should be conducted before these

treatment methods in children with neurologic

methods are put into effect as valid and reliable

disorders.(14,22,23) Thus, this study describes the effects

alternative treatment options for constipation in

of stretching exercises on constipation in children

Spastic Cerebral Palsy.

with CP. There are numerous studies conducted in children to investigate the efficacy of different

with

Volume I, Issue I

stretching

exercises

and

visceral

References

These

1. Guidice ED, Staiano A, Capano G, et al.

studies used osteopathic management based on nearly

Gastrointestinal manifestations in children with

the same assumption similar to this study (decreasing

cerebral palsy. Brain Dev 1999; 21:307-11.

treatment methods for constipation.

(8, 23).

spasticity, improving mobility). Thus, they formed

2. Campanozzi A, Capano G, Miele E, et al. Impact

the basic references for the current study. In a review

of malnutrition on gastrointestinal disorders and

of 4 studies,

(14, 24, 25)

. It is showed that there were

important improvements of the symptoms.. The limited ambulatory function in highly disabled

gross motor abilities in children with cerebral palsy. Brain Dev 2007; 29:25-9.

3. Sony

KF,

Chong

FRCP.

Gastrointestinal

children with CP along with increased level of

problems in the handicapped child. Curr Opin

spasticity is one of the major factors affecting the

Pediar 2001; 13:441-6.

digestive system. In our study, indicating a high level

4. 4. Sullivan PB. Gastrointestinal disorders in

of disability, chronic constipation with stomach pain,

children with neurodevelopmental disabilities.

muscle cramps, and incomplete defecation of feces

Dev Disabil 2008; 14:128-36.

may lead to increased spasticity levels, which in turn

5. Morad M, Nelson NP, Merrick J, Davidson PW,

may aggravate constipation further. Not surprisingly,

Carmeli E. Prevalence and risk factors of

it is also showed that relief in such constipation

constipation in adults with intellectual disability

symptoms also caused a significant decrease in

in residential care centers in Israel. Res Dev

overall spasticity levels. If visceral mobilization

Disabil 2007; 28:580-6.

techniques also be incorporated in the management,

6. Bishop PR, Nowicki MJ. Defecation disorders in

the results of the treatment may improve further and

the neurologically impaired child. Pediatr Ann

these results can be achieved very fast.

1999; 28:322-9.

7. Urbonas V, Ivanauskiene V, Sinkeviciene J,

Conclusion This case report highlights the use of stretching exercises for the treatment of a patient with spastic cerebral palsy. Stretching exercises have a role to reduce the spasticity and constipation in patient with the

spastic

CP.

However,

the role of stretching exercises is still unclear in the improvement of constipation. It is recommended that

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International Journal of Rehabilitation Sciences (IJRS)

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9. Alcantara J, Mayer DM. The successful

Constipation Assessment Scale for use in

chiropractic care of Pediatric patients with

pediatric oncology. J Pediatr Oncol Nurs

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23. Chown M, Whittamore L, Rush M, Allan S, Stott

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24. Staiano A, Del Giudice E, Simeone D, Miele E, Marino A. Cisapride in neurologically impaired

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15. Hundscheid HW, Pepels MJ, Engels LG, Loffeld RJ. Treatment of irritable bowel syndrome with

children with chronic constipation. Dig Dis Sci 1996;41:870-4.

osteopathy: results of a randomized controlled

25. Ernst E. Abdominal massage therapy for chronic

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International Journal of Rehabilitation Sciences (IJRS)

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January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

Volume I, Issue I

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International Journal of Rehabilitation Sciences (IJRS)

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January-June 2012

International Journal of Rehabilitation Sciences (IJRS)

Volume I, Issue I