IJPTVol2Iss1Jan Jun14 2

See discussions, stats, and author profiles for this publication at: https://www.researchgate.
net/publication/271202503
MUSCULOSKELETAL PAINAND INJURY IN PROFESSIONAL DANCERS:

PREVALENCE, PREDISPOSING FACTORS AND TREATMENT
Article · June 2014
CITATIONS READS
7 4,725
3 authors, including:
Happiness Anulika Aweto

University of Lagos
27 PUBLICATIONS 171 CITATIONS
SEE PROFILE
Some of the authors of this publication are also working on these related projects:
functional performance among children with brachial plexus birth palsy View project
Chest Physiotherapy for patients with COVID-19 View project
All content following this page was uploaded by Happiness Anulika Aweto on 22 January 2015.
The user has requested enhancement of the downloaded file.

Indian Journal of Physical Therapy
www.indianjournalofphysicaltherapy.com
Editor
Dr. Dinesh M. Sorani,
M.P.T. (Physical & Functional Diagnosis),
Senior lecturer,
Government Physiotherapy College, Jamnagar
Email:
editor@indianjournalofphysicaltherapy.com
Phone: +91-9426786167
Associate Editor
Dr. Paras Joshi
M.P.T. (Neurological Conditions)
I/C H.O.D. Physiotherapy Department,
Civil Hospital, Rajkot.
Advisory Board
Dr. Nita Vyas (Ph. D.)
Principal,
S.B.B. College of Physiotherapy,
Ahmedabad
Dr. Anjali Bhise

M.P.T. (Cardio-Pulmonary Conditions)
Principal,
Government Physiotherapy College,
Ahmedabad
Dr. Yagna Shukla

M.P.T. (Orthopedic Conditions),
Senior Lecturer,
Government Physiotherapy College,
Ahmedabad
Dr. Sarla Bhatt

Former Principal,
Shri. K. K. Sheth Physiotherapy College,
Rajkot
Editor’s Desk
Dear Physiotherapists,
It gives me immense pleasure to declare the third issue of Indian Journal of Physical
Therapy. To make more convenient for readers Indian Journal of Physical Therapy has also
launched e-jounral free for interested candidates. Hoping for best response for this time also
from readers. I want to take the opportunity to congratulate all the authors who has put their
efforts and sent their research work to us.
The third issue of Indian Journal of Physical Therapy includes research articles from
most of specialties of physiotherapy. Readers are requested to give their suggestions and
feedback regarding this issue.
Thanks.
Dr Dinesh M Sorani
Editor
January-June 2014, Volume. 2, Issue. 1
INDEX
1 DURATION OF MAINTAINED HAMSTRING FLEXIBILITY GAINS AFTER A ONE-TIME, MODIFIED HOLD- 1
RELAX STRETCHING PROTOCOL IN FEMALES.
RATHORE P, GARNAWAT D, RAGHAV D, SHARMA M, PAJNEE K, AGGARWAL T
2 MUSCULOSKELETAL PAIN AND INJURY IN PROFESSIONAL DANCERS: PREVALENCE, PREDISPOSING 6

FACTORS AND TREATMENT
HAPPINESS ANULIKA AWETO, OLUWAPELUMI MARIAM AWOLESI, RACHAEL OLUMAYOKUN ALAO
3 A STUDY TO EVALUATE THE HEMODYNAMIC RESPONSE TO REPETITIVE MCKENZIE EXERCISE IN 14

HEALTHY SUBJECTS
PURVI CHANGELA NANDANI
4 COMPARISON OF THE EFFECT OF CHAIR RISING EXERCISE AND ONE-LEG STANDING EXERCISE ON 22
DYNAMIC BODY BALANCE IN GERIATRICS: AN EXPERIMENTAL STUDY
KAJAL CHAUHAN, MEGHA SHETH, NEETA VYAS
5 A STUDY TO FIND OUT THE CORRELATION BETWEEN HANDGRIP STRENGTH AND HAND SPAN 27
AMONGST HEALTHY ADULT MALE
NANDANI MILIN
6 AWARENESS AND KNOWLEDGE OF PHYSIOTHERAPY AMONG THE GENERAL PUBLIC IN AN AFRICAN 32

MARKET IN ACCRA METROPOLIS, GHANA
OLAJIDE A. OLAWALE, MAGDALINE T. ADJABENG
7 A COMPARATIVE STUDY OF ULTRASOUND AND EXERCISE VERSUS PLACEBO ULTRASOUND AND 37

EXERCISE IN PATIENT WITH ORAL SUBMUCOUS FIBROSIS
PRIYANK GALCHAR, NEELA SONI, ANJALI BHISE
8 TO ASSESS AND COMPARE THE SHORT TERM EFFECT OF ATLANTO-OCCIPITAL JOINT MANIPULATION 42
AND SUBOCCIPITAL MUSCLE INHIBITION TECHNIQUE ON ACTIVE MOUTH OPENING RANGE
KHYATI HARISH SANGHVI, GANESH SUBBIAH, AMRIT KAUR
9 AN ANALYTICAL STUDY TO FIND OUT THE EFFECTS OF FOUR ASANAS ON DECREASING BLOOD 46
PRESSURE AND TO COMPARE IMMEDIATE EFFECTS ON BLOOD PRESSURE OF FOUR DIFFERENT
SEQUENCES OF COMMON ASANAS USED IN TREATMENT OF HYPERTENSION
GAGNIKA KAPOOR
10 TO STUDY THE EFFECT OF PROPIOCEPTIVE NEUROMUSCULAR FACILITATION VERSUS WEIGHTED 51

EXERCISES TO IMPROVE STAIR CLIMBING TASK IN CHRONIC STROKE PATIENTS- A COMPARITIVE
STUDY
BHATRI PRATIM DOWARAH, ARJUN SINGH TANWAR
11 EFFECTIVENESS OF MANUAL TRACTION OF TIBIO-FEMORAL JOINT ON THE FUNCTIONAL OUTCOME IN 56

KNEE JOINT OSTEOARTHRITIS
ANTONY LEO ASEER P, IYER LAKSHMI SUBRAMANIAN
12 DOES POLARIZED LIGHT THERAPY IMPROVE CHRONIC MAXILLARY RHINOSINUSITIS? 62

ASHRAF HASSAN MOHAMMED, ANEES G.SALEH, ZIZI MOHAMMED IBRAHIM
13 EFFECT OF CRANIOCERVICAL FLEXOR TRAINING AND CERVICAL FLEXOR TRAINING ON SITTING NECK 66
POSTURE IN PATIENTS WITH CHRONIC NECK PAIN; COMPARATIVE STUDY
KARTHIKEYAN, MOORTHY
14 EFFECT OF BALANCE EXERCISES ON BALANCE, PAIN AND FUNCTIONAL PERFORMANCE IN 71

OSTEOARTHRITIS KNEE
ANJALI GOEL, SHAGUN AGRAWAL, MEENAKSHI VERMA
15 EFFECTIVENESS OF SCAPULAR STABILITY EXERCISES IN THE PATIENT WITH THE SHOULDER 79

IMPINGEMENT SYNDROME
MAULIK SHAH, JAYSHREE SUTARIA, ANKUR KHANT
16 PREVALENCE OF LOW BACK PAIN DUE TO ABDOMINAL WEAKNESS IN COLLEGIATE YOUNG FEMALES 85
PARASHAR P, R. ARUNMOZHI, KAPOOR C
Indian Journal of Physical Therapy, Volume 2 Issue 1
DURATION OF MAINTAINED HAMSTRING FLEXIBILITY GAINS

AFTER A ONE-TIME, MODIFIED HOLD-RELAX STRETCHING
PROTOCOL IN FEMALES.
Rathore P1, Garnawat D2, Raghav D3, Sharma M4, Pajnee K5, Aggarwal T6
1. MPT (Cardio-Pulmonary), Assistant Professor, Santosh Medical College and Hospital, Ghaziabad, Uttar
Pradesh.
2. MPT (Cardio-Pulmonary), Physiotherapist, Dr.R.M.L Hospital, New Delhi.
3. MPT (Musculoskeletal), Principal, Santosh Medical College and Hospital, Ghaziabad, Uttar Pradesh.
4. MPT (Neurology), Assistant Professor, Santosh Medical College and Hospital, Ghaziabad, Uttar
Pradesh.
5. MPT (Sports medicine), Assistant Professor, Santosh Medical College and Hospital, Ghaziabad, Uttar
Pradesh.
6. MPT (Musculoskeletal), Assistant Professor, Santosh Medical College and Hospital, Ghaziabad, Uttar
Pradesh
ABSTRACT
AIM: To measure the duration of maintained hamstring flexibility gains after a one-time, modified hold-relax stretching
protocol in young healthy females.
BACKGROUND: The hamstring muscle are important contributory to the control of human movement and are involved
in a wide range of activities from running and jumping to forward bending during sitting or standing and a range of
postural control action. Hamstring muscle strains are the most common muscle injuries in athletes because of insufficient
flexibility strength.
METHODS: A total of 30 female subjects were selected on the basis of inclusion and exclusion criteria and divided into
two groups A and B. Group A as experimental included 15 subjects having hamstring tightness with mean age of [121.133
+ 2.0656], mean weight of [55.000 + 9.2505] and mean height of [158.00 + 7.020] and they were subjected to hold-
relax stretching protocol. Group B as control included 15 subjects having hamstring tightness with mean age of [22.000
+ 1.3628], mean weight of [53.467 + 8.6921] and mean height of [157.40 + 5.962] were lying supine after warm up.
And then measurements were taken before and after stretching at immediate (0min), 2, 4, 6, 8 and 10 min for both the
groups.
RESULT: Paired Sample t-test within the groups for both the groups and result of pre stretch vs. different durations
showed significant difference (p=0.0001). Independent t-test between the groups for both control & stretched limb showed
non-significant difference in the pre stretch value and significant difference for post stretch values. ANOVA of post stretch
within the group for stretched and controlled limb showed significant difference (p=0.0001).
CONCLUSION: Modified Hold-relax stretching increased the duration of hamstring flexibility after one-time hold-relax
stretching protocol.
KEYWORDS: Hamstring, Modified Hold-relax stretching, Active knee extension, flexibility
INTRODUCTION of flexibility gains after a single stretching session

has received limitation study.
Flexibility is a key component for injury, Hamstring stretching is popular among
prevention and rehabilitation. Stretching is physical therapists, athletics, trainers and fitness /
important for reducing injury and improving coaching professionals, who all have an interest in
performance in sports and for overall physical improving flexibility in both asymptomatic and
fitness. Athletes are often given stretching symptomatic clinical. Hamstring strain is a
protocols to improve their flexibility. Several common in athletics injury with a tendency to
stretching techniques are used to increase ROM. recur. Lack of flexibility has been suggested as a
Flexibility is the ability to move a joint through a predisposing factor to hamstring strains.
series of articulations in a full non-restricted pain- Clinicians are generally consider flexibility
free range of motion (ROM)2. A number of training to be an integral component in prevention
previous studies have demonstrated that PNF and rehabilitation of injuries as well as a method
stretching techniques produce greater increase in of improving one’s performance in daily activities
ROM than passive stretching method1,7,8,12. The and sports3.
technique used, flexibility gains in the hamstring The hamstring muscle are important
muscle have been demonstrate after a multiple- contributor to the control of human movement and
day stretching program, and some studies have are involved in a wide range of activities from
shown that frequency and duration of PNF running and jumping to forward bending during
stretching affect ROM gain. However the duration sitting or standing and a range of postural control
action. The proposed etiology involved
-----[1]-----
insufficient flexibility strength (force generating from full knee extension as determined by active
capacity) impairment or imbalance a dyssynergic knee extension (AKE) test5. The subject were
contraction that can place excessive strain on the positioned in supine where the right hip
hamstring muscle. Static stretching of the maintained in 0o flexion and left lower extremity
hamstring muscle to maintain flexibility and was placed in 90o of hip flexion with knee 90o
improve performance has been proposed as a flexion with the help of cross bar. The subjects left
proactive and preventive strategy and is now in hip was flexed at 90o until the anterior thigh just
common use in studies. Reduce hamstring muscle touch the cross bar of the alignment of apparatus
flexibility has been implicated in lumbar spine the right hip was perpendicular to the horizontal
dysfunction with a number of studies showing a surface of the table for all AKE measurement.
strong positive correlation between decreased Throughout the AKE procedure, the right hip
hamstring flexibility and low back pain3. remained at 0o of flexion. The fulcrum of the
However one of the literature view goniometer was placed on the lateral epicondyle
“Effect of stretching position hamstring flexibility of the femur, the stationary arm was aligned with
gains” 4, the result has shown that ROM gained in the line joining greater trochanter and lateral
supine is greater than standing position will be epicondyle of the femur and movable arm was
used to gain the maximum flexibility. Thus the aligned with the line joining the lateral epicondyle
present study was done to evaluate the duration of of the femur and lateral malleolus to measure knee
maintained hamstring flexibility gains after a one range of motion. All the subjects were then asked
time modified hold relax stretching protocol in to perform 6 warm-ups active knee extension with
females. a 60 sec rest period between repetitions. The first
5 AKEs served as warm-up to decrease any effect
METHOD that may occur with repeated measures are
performed from cold start. The 6th AKE was
SUBJECTS recorded as the prestretch measurement. When the
subject could not extend her lower leg any further
This was experimental study with 30 without her thigh moving away from the cross-
females with hamstring tightness. Characteristics bar, she inform the examiner and held that
of sample are described in Table.1 position for approximately 2 to 3 sec. until a
measurement was taken.
TABLE 1 The 15 subjects of experimental group
p value
received visual and verbal predetermined time
Demographic variables t value
0.186
intervals for stretching, contracting and relaxing
Age 1.356
0.644
were used for stretching. The examiner passively
Weight 0.468
0.803
stretched the hamstring until the subject first
Height 0.252
reported a mild stretch sensation and held that
position for 7 seconds. Next the subject maximal
All 30 female subjects were selected on isometrically contracted the hamstring for 7
the basis of inclusion and exclusion criteria and seconds by attempting to push her leg towards the
divided into 2 groups A and B. The subjects were table against the resistance of the examiner. After
recruited from the department of physiotherapy, the contraction, the subject relaxed for 5 sec. This
dolphin (PG) institute of biomedical and natural sequence was repeated 5 times on each subject in
sciences Dehradun. The inclusion criteria were the experimental group for left extremity. Then
age between 17-23year, young healthy female post-stretch measurement were performed in the
with hamstring tightness (limitation of 200 or same manner as pre-stretch measurement. AKE
more from full extension of knee). Subjects with measurement was taken at 0 minute
injury to trunk and lower extremity for previous 6 (immediately), 2, 4, 6, 8, 10 minutes after the final
months, mental retardation and hypermobility of stretch in the experimental group and
hip and knee joint were excluded. measurement of the angle of knee joint ROM was
recorded. Whereas the control group lay supine on
PROCEDURE the table for 5 minutes. Then the control group
The subject found suitable on the basis of underwent the same post-stretch measurement
inclusion and exclusion criteria were requested to protocol immediately after 5 minutes of lying
sign the written informed consent forms. The quietly on the table at 0 minute (immediately), 2,
study and consent form were approved by the 4, 6, 8, 10 minutes. Measurement of angle of knee
institutional ethics review committee. The ROM was recorded.
subjects were then randomly assigned to the two
groups (Group A and Group B) following lottery
method. They had a visible evidence of hamstring
tightness, defined as a limitation of 20o or more
-----[2]-----
DATA ANALYSIS result of prestretch Vs starting min (p=0.0001),

prestretch Vs two minutes (p=0.0001), prestretch
Data was analyzed using SPSS (12.0) Vs four minutes (p=0.0001), prestretch Vs six
version. Paired sample “t-test” was done within minutes (p=0.0001), Prestretch Vs eight minutes
the group for controlled and stretched limb. (p=0.0001) and prestretch Vs ten minutes
Independent “t-test” was done between the groups (p=0.0001) showed significant difference as in fig
for stretched and controlled limb to determine the 1.2.
significance level of pre and post-stretch.
ANOVA of the post-stretch within the group was
Active Knee Extension

60
done for both stretched and controlled group and 50
to determine the significance levels for both the 40
30
groups 20 Prestretch
10 Duration
0
RESULT Prestretch Prestretch Prestretch Prestretch Prestretch Prestretch
0 min 2 min 4 min 6 min 8 min 10 min
Duration
Mean values and Standard Deviations of

the outcome variables during both the tests are
displayed in Table 2 and Table 3 FIGURE 2: GRAPHICAL REPRESENTATION
OF THE COMPARISON OF PRESTRETCH
TABLE 2: INDEPENDENT ‘T’ TEST BETWEEN VERSUS DIFFERENT DURATION FOR GROUP
THE GROUPS B
Mean ± SD Mean ± SD p value

Duration
(Group A) (Group B)
Independent “t-test” was done between
36.33± 4.86 35.33±6.03 0.621 the groups for both control and stretched limb, and
Prestretch
22.53 ± 7.20 37.87±5.88 0.001 the result of prestretch (p=0.621), showed
Zero min.
25.60 ±6.41 39±5.95 0.001 insignificant difference whereas starting min
Two min.
28.93 ±6.32 41.60±5.75 0.001 (p=0.0001), two minutes (p=0.0001), four
Four min.
32.60 ±5.93 43.60±5.79 0.001 minutes (p=0.0001), six minutes (p=0.0001),
Six min.
36.33 ± 5.58 45.60±5.79 0.001 eight minutes (p=0.0001) and ten minutes
Eight min.
39.73 ± 5.09 47.67±5.90 0.001 (p=0.0001) showed significant difference as
Ten min.
shows in table 2 and fig. 1.3.
60
Independent sample “t-test” was done
50
between the two groups of age, height and weight 40
and the result showed insignificant difference in 30
Group A
Group B
Age (p= 0.186), weight (p=0.644) and height 20
(p=0.803) [Table-1]. 10
Paired sample “t-test” was done within 0
the group A for stretched limb and result of Prestretch 0 min 2 min 4 min 6 min 8 min 10 min
Duration
prestretch Vs starting min (p=0.0001), prestretch
Vs two minutes (p=0.0001), prestretch Vs four
minutes (p=0.0001), prestretch Vs six minutes FIGURE 3: GRAPHICAL REPRESENTATION
OF THE COMPARISON OF GROUP A AND B
(p=0.0001), Prestretch Vs eight minutes
(p=0.0001) and prestretch Vs ten minutes
ANOVA of post-stretch within the group
(p=0.0001) showed significant difference as
was done and the result of group A for stretched
shows in fig 1.
limb (p=0.0001) and group B for control limb
(p=0.0001), showed significant difference,
50
40
[Table-3].
Prestretch
30
20
Duration
10 TABLE 3: ANOVA OF POST-STRETCH
0
Prestretch Prestretch Prestretch Prestretch Prestretch Prestretch
WITHIN THE GROUPS
0 min 2 min 4 min 6 min 8 min 10 min
Duration
Groups F value P value
Group A 16.96 0.0001
FIGURE 1: GRAPHICAL REPRESENTATION Group B 5.98 0.0001
OF THE COMPARISON OF PRESTRETCH
VERSUS DIFFERENT DURATION FOR GROUP
A
DISCUSSION
Similarly paired samples “t-test” was Flexibility is a key component for injury
done within the group B for controlled limb and prevention and rehabilitation. Stretching is
-----[3]-----
important for reducing injury and improving significant difference between static or PNF
performance in sports and for overall physical stretching technique in anterior pelvic tilt.
fitness. Athletes are often given stretching
protocols to improve their flexibility. Several FUTURE RESEARCH
stretching techniques are used to increase joint
range of motion (ROM)6. • It can be done by including the more
The purpose of this study was to measure number of samples.
the duration of maintained hamstring flexibility • It can also be done by increasing the time
gains after a one-time, modified hold-relax of research.
stretching protocol in young females. In this study • It can be done by taking older people.
the hypothesis was that the PNF stretching • It can also be done on other group of
technique (Hold-Relax) will increase the duration muscles
of maintained hamstring flexibility.
In this study, ANOVA was done to
compare each post-stretch measurement to
RELEVANCE TO CLINICAL
determine the significant difference among the PRACTICE
two groups. The result showed significant
difference for the group The hamstring tightness subject
In a previous study using a static indicated an increased amount of flexibility after
stretching protocol, hamstring flexibility one-time modified hold-relax stretching. These
increased significantly but only remained findings may have clinical implication in terms of
increased for 3 minutes after stretching.3 how often a stretching routine should be
Although another studies supported greater performed in a day to maintained flexibility gains,
increases in ROM with PNF stretching techniques especially if a person had primarily sedentary life
than with passive, static, or ballistic stretching style
methods1,7,8,12. However, some studied suggest no
difference between PNF and other stretching CONCLUSION
techniques9,10.
One of the study was done by William It was concluded that modified hold-
D Bandy et al on The effect of time on static relax stretching increased the duration of
stretch on the flexibility of hamstring muscle hamstring flexibility after one-time hold-relax
suggested that duration of 30 sec is an effective stretching protocol in young female.
time of stretching for enhancing the flexibility of
hamstring muscle. Occurred by increasing the ACKNOWLEDGEMENT:
duration of stretching from 30 to 60 sec is more
effective11. The author acknowledges support of DR.
Moreover, a review by Sady SP et al on Promod Kumar Rathore, MDS (periodontics), Sr.
Flexibility training by using ballistic, static or Lecturer in Shree Bankey Bihari dental college.
proprioceptive neuromuscular facilitation
suggested that flexibility training by ballistic
static or PNF indicates that PNF may be the
preferred technique for improving flexibility1. CONFLICT OF INTEREST
Another study using static stretching
protocol by Glen M. DePino et al which was on There is no conflict of interest.
the Duration of maintained Hamstring Flexibility
after cessation of an acute static Stretching REFERENCES
protocol and they were suggested that hamstring
flexibility significantly improved of knee 1. Sady SP, Wortman M, Blanke D. Flexibility
estimation ROM in the experimental group that training by using ballistic, static or PNF. Arch
was lasted for 3 minutes3. phys med rehabil; 63(6): 261-263, 1982.
Sullivan MK et al10, studied on the Effect 2. Michael R., Effect of lower extremity
of pelvic position and stretching on hamstring position & stretching on hamstring muscle
muscle flexibility and showed the comparison of flexibility. Journal of strength and
static stretching and PNF techniques while conditioning research, 1999, 13(2), 124-129.
maintaining the pelvis in anterior or posterior 3. Glen M. De Pino, William G. Webright,
pelvic tilt. They used ANOVA comparing Brent L. Arnold. Duration of maintained
stretching technique and pelvic position revealed hamstring flexibility after cessation of an
those anterior pelvic tilt groups significantly acute static stretching protocol. Journal of
increase the hamstring flexibility. There was not a athletics training; 35(1):2000.
4. Decoster L C, Cleland J, Altieri C, and
-----[4]-----
Russell P. Effect of stretching position on 9. Worrell TW, Smith TL, Winegardner J.

hamstring flexibility gains. J orthosports Effect of hamstring stretching on hamstring
phys. Ther; 35(6): 377-382, 2005. muscle performance. J orthop sports phys
5. Adler SS., Becker D, Buck M. PNF in ther; 20(3): 154-159, 1994.
practice. An illustrated guide. 2nd ed. revised 10. Sullivian MK, Dejulia JJ. Effect of pelvic
edition reprint: 43, 2003. position and stretching method on Hamstring
6. Scott G. Spernoga, Timothy L. Uhl, Brent L. muscles flexibility. Med sci sports exercise;
Arnold, Bruce M. Gansneder. Duration of 24: 1383-1389, 1992.
maintained hamstring flexibility after a one- 11. Bandy WD, Irion. The effect of time and
time, modified hold-relax stretching protocol. frequency of static stretching on flexibility of
J Athl Train; 36(1):44-48, 2001. hamstring muscle. Phy Thera; 78(3):321-322,
7. Willin D, Ekblom B, Grahn R, Nordenborg T. 1988.
Improvement of muscles flexibility in a 12. Etnyre BR, Abraham LD. Gains in range of
comparison between two techniques. AM J ankle dorsiflexion using three popular
sports med; 13(4):263-268, 1985. stretching techniques. AM J phys. Med;
8. Osterning LR, Robertson RN, Troxel RK, 65(4); 189-196, 1986.
Hansen P. Differential responses to PNF
stretching technique. Med sci sports exercise;
22(1): 106-111, 1990.
-----[5]-----
MUSCULOSKELETAL PAIN AND INJURY IN PROFESSIONAL

DANCERS: PREVALENCE, PREDISPOSING FACTORS AND
TREATMENT
Happiness Anulika Aweto1, Oluwapelumi Mariam Awolesi2, Rachael Olumayokun
Alao3
1. Lecturer, Department of Physiotherapy, College of Medicine, University of Lagos, Idi-Araba, Lagos,
Nigeria.
2. Department of Physiotherapy, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
3. Senior Physiotherapist, Department of Physiotherapy, Lagos University Teaching Hospital, Idi-Araba,
Lagos, Nigeria.
ABSTRACT
BACKGROUND: Dance- related musculoskeletal injury and pain have been described as a physical condition that
causes discomfort resulting in a limitation, restriction or cessation in participation in dance. This study investigated the
prevalence of musculoskeletal pain and injury among professional dancers in Lagos state, Nigeria.
METHOD: The study was a cross sectional descriptive survey. One hundred and eighty (180) professional dancers (95
male and 85 female) selected from 10 dance groups in Lagos state, Nigeria completed a 31-item questionnaire. They
were selected using a sample of convenience technique.
RESULTS: A 12-month prevalence of musculoskeletal disorders and pain was 86.1 %. Fifty six (36%) respondents had
injury at the time of study while 91 (58%) had the injury two to four weeks before the study. The most commonly affected
body parts were the knee (54.8%), the lower back (32.9%) and the ankle (25.2%). 56.7% of the respondents reported
having strain. Eighty four (54.1%) respondents reported that injury occurred during training mainly while attempting
skills beyond ability. Sixty three (35%) respondents had self-treatment. Chi-square analysis showed that there was a
statistically significant association between the frequency of training per week and the prevalence of musculoskeletal
pain and injury.
CONCLUSION: There was high prevalence of musculoskeletal pain and injury among professional dancers in Lagos
state, Nigeria. Injury occurred mainly while attempting skills beyond their abilities especially during training. Increased
training periods per week is a significant factor contributing to the high level of musculoskeletal pain and injury.
KEYWORDS: Musculoskeletal pain, injury, professional dancers.
puberty), extensive and intense rehearsals,

INTRODUCTION insufficient warm-up, fatigue, technical errors,
physical characteristics of footwear, inappropriate
Dance is an art form that generally refers or ill-maintained dance floors, and dietary habits
to movement of the body, usually rhythmic and to common to dancers7,8. Dance-related injuries
music, used as a form of expression, social usually result from inherent biomechanical
interaction or presented in a spiritual or factors, environmental and training issues, as well
performance setting1. It not only involves as technical competence. The rates of injuries
flexibility and body movement, but also physics appear almost twice as high in male dancers as in
of the body. If the proper physics is not taken into female dancers. Gender differences in injury
consideration, injuries may occur2. World Health characteristically result from differences in
Organization (WHO) defined a dance injury as “a imbalance, inflexibility and strength as well as
physical condition that causes pain or discomfort differences in performance of specific roles 9. Men
resulting in a limitation, restriction or cessation in are more inclined to ankle and back injuries
participation in dance3-5. because of the jumping, leaping, and lifting that
Dancers are a unique blend of artist and their roles often require10. Age may also have a
athlete particularly susceptible to musculoskeletal significant impact on injury incidence. Adolescent
injuries and pain which can be difficult to dancers may be more subject to overload injury
diagnose6. Musculoskeletal injury is the most because of muscle tissue quality and technical
frequently reported medical problem among skill typical of that age. There is evidence to show
classical and modern dancers. It affects dancing that as dancers age they are likely to be more
performance, hinders participation in dance, and aware of the warning signs of injury and to take
may result in temporary unemployment, loss of steps to prevent it11. Injuries are also more likely
salary or an end to a career of a professional to occur in the late afternoon, a reflection of
dancer7. The high incidence of injury in dancers muscular and psychological fatigue5.
has been attributed to several factors including; Overuse injuries account for 60-76% of
excessive dance training at an early age (before all dance injuries and most injuries affect the
-----[6]-----
lower extremities and back12. The most common and pie charts. The level of significance was
locations for injuries are ankles, lower leg/calf, p<0.05.
and back, usually caused by overuse, muscle
strains, and sprains13. Musculoskeletal conditions RESULTS
often manifest with the onset of pain and the
resulting physical limitations. It is one of the most The mean age, years of professional
common reasons for self-medication and entry dancing and training hours per day of the
into the health care system14. Knowing how to respondents were 24.2 ± 4.36 years, 5.20 ± 3.40
evaluate, treat, and prevent disorders in this years and 3.60 ± 3.40 hours respectively (Table 1).
unique population will help optimize patient One hundred and twenty two (67.8%) of the
outcomes15. The problems of musculoskeletal respondents danced contemporary while 15
pain and injuries among professional dancers have (8.3%) danced jazz (Fig 1). One hundred and fifty
not been extensively explored in Nigeria. Hence, five (86.1%) of the respondents reported that they
this study was designed to investigate the had injury or pain within the last 12 months of the
prevalence of musculoskeletal pain and injury study while 25 (13.9%) reported they did not have
among professional dancers in Lagos, Nigeria. pain or injury (Fig 2). Concerning the point
prevalence of musculoskeletal pain and injury, 56
MATERIALS AND METHODS (36%) respondents had injury at the time of the
study while 91 (58%) had injury within the last
One hundred and eighty (180) one to two weeks of the study (Fig 3).
professional dancers (95 male and 85 female) Eighty eight (48.9%) respondents
selected from 10 dance groups in Lagos state, attributed their injury and pain to dance while 48
Nigeria participated in the study. They were aged (26.7%) did not (Table 2). Twenty eight (15.6%)
18 years to 40 years and were selected by a sample respondents got injured monthly while 5 (2.8%)
of convenience. Ethical approval was obtained had pain or injury daily (Table 3). Four most
from the Research and Ethics Committee of the injured parts of the body were the knee, lower
Lagos University Teaching Hospital, Idi-Araba, back, ankle and shoulder/hip. Eighty five (54.8%)
Lagos. An informed consent was attached to a respondents had injury and pain at the knee, 51
structured 31-item questionnaire which each of (32.9%) at the lower back and 5 (7.1%) at the shin
the participants completed. This questionnaire (Fig 4). The knee was the most injured part of the
titled ‘Prevalence of musculoskeletal pain and body for such dance types as Hip hop,
injury in professional dancers’ was adopted from Contemporary, African contemporary and
a previous epidemiological study of injuries in African dance (Fig 5). Twenty two (12.2%)
highland dancers by Logan-Krogstad16 but was respondents had pain severity rated 4 while 2
slightly modified by a panel of 5 experienced (1.1%) had 10 (Table 4). One hundred and two
clinical and academic physiotherapists to suit the (56.7%) respondents had strain as the type of
purpose of this study. The questionnaires were injury while 3 (1.7%) had tendonitis (Fig 6).
first given to ten model subjects to fill in order to Eighty four (54.1%) respondents reported that the
ascertain if the questions were easy to understand injury occurred during the training periods while
and were suitable for data collection. It had six 20 (12.9%) reported during warm-ups (Table 5).
sections. Section A (items 1-3) collected One hundred and twenty six (70%) respondents
information on the demographic data of the had the injury suddenly while 106 (58.9%) had
participants. Section B (items 4-11) collected gradual onset of injury (Fig 7). Sixty six (36.7%)
information on the professional dance history of respondents reported that the injury was caused by
participants, section C (items 12-24) collected attempting skills beyond ability while 2 (1.1%)
information on the prevalence musculoskeletal reported that it was caused by fatigue (Table 6).
pain and injury, section D (items 25-26) collected Sixty five (36.1%) respondents modified
information on the predisposing factor to their training as a coping strategy while 115
musculoskeletal pain and injury, section E (items (63.9%) respondents did not modify their training
27-29) collected information on the participants’ (Fig 8). Eighty eight (56.7%) respondents did not
limitations due to pain and injury and section F miss on either training or performance while 26
(items 30-31) collected information on the (16.8%) missed performance (Table 7). One
participants’ treatment history. hundred and twenty two (78.7%) of the
respondents who had musculoskeletal pain and
DATA ANALYSIS injury received treatment while 33 (21.3%) of
them did not receive treatment (Fig 9). Sixty three
Descriptive statistics of frequency,
(35%) respondents had self-treatment while 48
percentages and inferential statistics of chi-square
(26.7%) received treatment from physiotherapy.
were used for data analysis. The results were
Some of the respondents had two or more types of
represented using tables, histograms, bar charts
treatment (Table 8). One hundred and fourteen
-----[7]-----
(73.5%) respondents reported that pain and injury TABLE 1: CHARACTERISTICS OF THE
did not affect their daily activities while 41 RESPONDENTS
(21.7%) reported that it affected theirs (Table 9). Mean ±
Chi-Square analysis showed that there SD
Age (years) 24.2 4.36
was no significant association between the Years of professional dancing 5.5 3.40
prevalence of musculoskeletal pain and injury and (years)
the age of professional dancers (ℵ = 13.70, = Hours of training 3.6 3.40
0.89) (Table 10), the type of dance (ℵ =

6.78, = 0.45) (Table 11) and the training hours TABLE 2: RESPONDENTS’ ASSOCIATION OF
MUSCULOSKELETAL DISORDERS TO
per day (ℵ = 13.82, = 0.05∗ ) (Table 12).
DANCE.
Chi-square analysis showed that there
was a significant association between the training Associating MSD to dance Frequency Percent
(n) (%)
time and prevalence of musculoskeletal pain and Yes 88 48.9
injury (13.82= 2‫א‬, p=0.05*) (Table 13). No 48 26.7
Not applicable 44 24.7
Total 180 100
Key: MSD = Musculoskeletal disorders
TABLE 3: HOW OFTEN THE RESPONDENTS

HAD INJURY
How often respondents had pain Frequency Percent

and injury (n) (%)
Daily 5 2.8
Weekly 17 9.4
Figure 1: Dance types Monthly 28 15.6
Never 27 15.0
Others 103 57.2
Total 180 100
TABLE 4: SEVERITY OF PAIN FELT BY THE

RESPONDENTS ON A SCALE OF ONE TO TEN.
Level of pain felt Frequency Percent
(n) (%)
0 77 42.8
1 4 2.2
Figure 2: Twelve months prevalence of 2 15 8.5
3 21 8.3
musculoskeletal disorders among professional 4 22 12.2
dancers 5 19 10.6
6 10 5.6
7 4 2.2
8 4 2.2
9 2 1.1
10 2 1.1
Total 180 100
TABLE 5: WHEN THE INJURY LIKELY

OCCURRED.
When the injury occurred Frequency Percent
(n) (%)
Training 84 54.1
Figure 3: Point prevalence of musculoskeletal Performance 28 18.0
disorders among professional dancers Warm up 20 12.9
Others 23 14.8
Total 155 100
TABLE 6: CAUSES OF INJURY

Causes of injury Frequency Percent
(n) (%)
Loss of balance 60 33.3
Attempting skill beyond ability 66 36.7
Fatigue 2 1.1
Insufficient warm 43 23.9
Loss of balance 8 4.4
Total 155 100
Figure 4: Areas of pain and injury
-----[8]-----
TABLE 7: MISSING TRAINING OR PERFORMANCE DUE TO PAIN OR INJURY

Frequency Percent
(n) (%)
Respondents who missed training 41 26.5
Respondents who missed performance 23 16.8
Respondents who did not missed training or performance 88 56.7
TABLE 8: TYPES OF TREATMENT RECEIVED BY RESPONDENTS
Types of treatment received Frequency Percent

(n) (%)
Doctor 50 27.8
Physiotherapy 48 26.7
Self medication 63 35.0
Figure 5: Areas of pain and injury due to different types of dance
Figure 8: Respondents’ modification of

training due to pain
Figure 6: Injury classification
Figure 9: Respondents who received

Figure 7: The nature of injury sustained by treatment
the Respondents
-----[9]-----
TABLE 9: PAIN AND INJURY AFFECTATION among professional dancers in Lagos state,
OF DAILY ACTIVITIES Nigeria. The 12 months prevalence of
If pain and injury affected Frequency Percent musculoskeletal pain and injury among
activities of daily living (n) (%) professional dancers was 86.1%. This implies a
Yes 41 21.7 high prevalence of musculoskeletal pain and
No 114 73.5
Total 155 100 injury among professional dancers in Lagos state,
Nigeria. The knee was the most frequently injured
TABLE 10: RELATIONSHIP BETWEEN AGE area especially for most of the dance types
AND PREVALENCE OF MUSCULOSKELETAL followed by the low back, ankle and then the
PAIN AND INJURY shoulder/hip. Over half of the professional
Prevalence X2 p-value
dancers had strain as the type of injury. Pain
Age
Yes No severity for most of the injured dancers was rated
18-20 34 8 average. Over half of the injured professional
21-25 42 6 dancers had the injury during the training periods.
13.70 0.89
31-35 7 1
36-40 4 0 Over two-thirds of the surveyed professional
dancers had the injury suddenly. Over a third of
TABLE 11: RELATIONSHIP BETWEEN THE the professional dancers had injury when
TYPE OF DANCE AND PREVALENCE OF attempting skills beyond their abilities. Over half
MUSCULOSKELETAL DISORDERS AMONG of the surveyed professional dancers neither
PROFESSIONAL DANCERS modified their training nor missed training /
Prevalence X2 p- performance as a result of musculoskeletal pain
Types of dance
Yes No value and injury. More than one-third of the
Hip hop 91% 8.6%
Contemporary 90% 9.8%
professional dancers who had musculoskeletal
African 86% 13.9% pain and injury went for self-treatment instead of
contemporary seeking treatment from professionals.
Ballroom 86.1% 13.8% 6.78 0.45
African dance 85.3% 14.7%
The high prevalence of musculoskeletal
Jazz 100% 0% pain and injury among professional dancers
Ballet 87.5% 12.5% observed in this study corroborates previous
Aerobic 94.4% 5.6%
studies4,12,17-20. Ruanne et al19 reported that
musculoskeletal injury rates in professional dance
TABLE 12: RELATIONSHIP BETWEEN
LENGTH OF TRAINING HOURS PER DAY
companies and pre-professional dancers range
AND PREVALENCE OF MUSCULOSKELETAL from 67% to 95%. Cho et al (2009)20 reported an
PAIN AND INJURY IN PROFESSIONAL injury rate of 95.2% among male Korean break-
DANCERS dancers.
The finding that the knee was the most
Training hours Prevalence X2 p-
per day Yes No value frequently injured area especially for most of the
1 hour 7 (4.5%) 1 (4.0%) dance types followed by the low back, ankle and
2 hours 13 (8.4%) 3 (12%) then the shoulder/hip corroborates previous
3 hours 32 10
(20.6%) (40.0%)
finding12,13,21. Anthony et al13 reported that the
5.28 0.26
4 hours 56 6 (24.0%) most common locations for injuries were the knee,
(36.1%) lower back, ankles and lower leg/calf. Bronner et
>5 hours 47 5 (20.0%)
(30.3%) al12 and Rickman et al21 observed that most
musculoskeletal disorders occurred at the lower
TABLE 13: RELATIONSHIP BETWEEN THE back and lower extremities. This may be as a
TRAINING TIME PER WEEK AND result of the anatomic structures of these areas and
PREVALENCE OF MUSCULOSKELETAL the demands made on them when performing the
DISORDERS AMONG PROFESSIONAL different dance routines. The joints of the lower
DANCERS extremities bear much of the weight of the body.
Training hours Prevalence X2 p-value Studies have shown that the occurrence of injuries
per day Yes No is related to the type of dance being performed, the
Once a week 12 1 dancers’ technique, experience, physiology and
Twice a week 28 5
Three times a week 58 18 psychological factors22-25. Shah et al18 observed
13.82 0.05*
Four times a week 36 1 that the foot and ankle was the most common site
Daily 17 0
Other 4 0 of injury, followed by the lower back and the knee
* = significant (p < 0.05) among professional contemporary dancers in the
USA. Rietveld and van de Wiel26 reported that
DISCUSSION dance injuries are often caused by faulty technique
due to compensation for physical limitations.
The study was designed to evaluate the Janey Holcer et al27 stated that many dancers often
prevalence of musculoskeletal pain and injury stretch their physical capabilities and endurance
-----[10]-----
and neglect their physical limitations. Again, seeking treatment from professionals corroborates
dance floors play a significant role in the previous studies which reported that injured
occurrence of acute and chronic injuries, even in dancers often fail to seek medical attention34,35.
experienced dancers28. It was observed that most This may be due to concerns for loosing time from
floors that the professional dancers in Lagos state, training and a feeling of not being understood by
Nigeria performed their dance were made of medical practitioners19.
concrete. Koutedakis29 observed that dancers who There was no significant relationship
danced on concrete floor had more injury than between prevalence of musculoskeletal pain and
those dancers that danced on properly sprung injury and age of professional dancers. This
floor. means that age of professional dancers did not
The fact that more than half of the predispose them to musculoskeletal pain and
professional dancers had strain as the type of injury, although professional dancers within the
injury may also be due to the forceful impact of ages of 21 and 25 years had the highest
dance upon the body and the different twisting prevalence. Stretanski and Weber36 observed that
movements that the joints and muscles are there was a significant relationship between the
subjected to when dancing. Anthony et al13 also age and prevalence of musculoskeletal pain and
observed that strain and sprain were common injury among professional dancers and that there
among professional dancers. Cho et al20 reported was high prevalence of musculoskeletal pain and
that sprain, strain and tendinitis accounted for the injury between the ages of 21 and 25 years.
most injury in break-dancers. There was no significant relationship
The finding that most of the injured between prevalence of musculoskeletal pain and
professional dancers rated the severity of their injury among professional dancers and the type of
pain as average may not be quite accurate as dance. Ruanne et al19 reported that the occurrence
perception of pain is not a valid indicator of the of injuries is related to the type of dance being
severity of pain19. This is because perception of performed.
pain varies widely among dancers and perceived There was no significant relationship
severity of pain is negatively correlated with the between prevalence of musculoskeletal pain and
levels of both skill and experience30,31. injury among professional dancers and the
The observation that more than two- training hours per day. Cho et al20 reported that the
thirds of the surveyed professional dancers had the number of injury sites was not significantly
injury suddenly may also be due to the forceful correlated with the amount of training in male
impact of the dance types upon the body Korean break-dancers.
especially the lower limbs. Bowling32 observed This study showed significant
that more than half of professional dancers have relationship between the time spent on training per
reported at least one chronic injury. Wong et al7 week and prevalence of musculoskeletal pain and
reported that majority of dance injuries are injury. This means that those who trained three
overuse injuries which usually develop slowly times a week had more musculoskeletal pain and
over time. injury than those that trained once. Clark et al37
Over half of the injured professional reported that dancers tend to have musculoskeletal
dancers had the injury during the training periods pain and injury when training is done more than
mainly while attempting skills beyond their once a week.
ability. Dancers go through rigorous training to
master new techniques through repetitive CONCLUSION
practices and this may pose a risk to injury as
anatomic and physiologic capabilities of body There was high prevalence of
structures are usually exceeded. Young et al33 musculoskeletal pain and injury among
found out that musculoskeletal injuries occurred professional dancers in Lagos state, Nigeria.
mainly during the end of training sessions due to Injury occurred mainly while attempting skills
fatigue and overuse of body structures. beyond their abilities especially during training.
The observation that more than half of Increased training periods per week is a
the surveyed professional dancers neither significant factor contributing to the high level of
modified their training nor missed training / musculoskeletal pain and injury. Self-treatment
performance as a result of musculoskeletal pain was the most commonly practiced treatment
and injury may be because they do not want to option by these dancers.
lose time from training. Shah et al18 also observed
that most professional contemporary dancers
missed no performances due to injury.
REFERENCES
The finding that more than one-third of
the professional dancers who had musculoskeletal 1. Ostwald PF, Baron BC, Byi NM, Wilson FR
pain and injury went for self-treatment instead of (1994). Performing arts medicine. Western
Journal of Medicine 160: 48-52.
-----[11]-----
2. Jacobs CL, Hincapie CA, Cassidy JD (2012). 17. Anderson BD (1999). Cost containment of a
Musculoskeletal Injuries and pain in dancers: professional ballet company through in-
a systematic review update. Journal of Dance house physical therapy. J Orthop Sports Phys
Medicine and Science 16(2):74-84. Ther. 29: A19.
3. Rothenberger LA, Chang JI, Cable TA 18. Shah S, Weiss DS, Burchette RJ (2012).
(1988). Prevalence and types of injuries in Injuries in professional modern dancers:
aerobic dancers. The American Journal of incidence, risk factors, and management. J
Sports Medicine 16(4): 403-407. Dance Med Sci. 16(1): 17-25.
4. Kerr G, Krasnow D, Mainwaring L (1992). 19. Lai R, Krasnow D, Thomas M (2008).
The nature of dance injuries. Medical Communication between Medical
Problems of Performing Artists 7(1): 25-29. Practitioners and Dancers. Journal of Dance
5. Krasnow D, Mainwaring L, Kerr G (1999). Medicine and Science 12(2): 47-53.
Injury, stress, and perfectionism in young 20. Cho CH, Song KS, Min BW, Lee SM, Chang
dancers and gymnasts. Journal of Dance HW, Eum DS (2009). Musculoskeletal
Medicine and Science 3(2): 51-58. injuries in break-dancers. Injury, Int. J. Care
6. Warren MP, Brooks-Gunn J, Hamilton LH Injured 40: 1207-1211.
(1996). Scoliosis and fractures in young 21. Rickman AM, Ambegaonkar JP, Cortes N
ballet dancers. Relation of delayed menarche (2012). Core stability: implications for dance
and secondary amenorrhea. English Journal injuries. Med Probl Perform Art. 27(3):159-
Med. 314(21):1348–53. 64.
7. Wong MWN, To WWK, Chan KM (1995). 22. Barrell GM, Terry PC (2003). Trait anxiety
Musculoskeletal injuries in different and coping strategies among ballet dancers.
disciplines of dancing. Proceedings in Med Probl Perform Art. 18(2): 59-64.
Western Pacific Orhopaedic Association 23. Patterson EL, Smith RE, Everett JJ, Ptacek JT
Congress, Hong Kong. (1998). Psychosocial factors as predictors of
8. Reid DC, Burnham RS, Saboe LA, Kushner ballet injuries: interactive effects of life stress
SF (1987). Lower extremity flexibility and social support. J Sport Behav. 21(1): 101-
pattern in classical ballet dancers and their 112.
correlation to lateral hip and knee injuries. 24. Poczwardowski A, Conroy DE (2002).
American Journal of Sports Medicine 15(4): Coping responses to failure and success
347-352. among elite athletes and performing artists. J
9. Garrick GJ (1999). Early identification of Appl Sport Psychol. 14(4): 313-329.
musculoskeletal complaints and injuries 25. Wainwright SP, Williams C, Turner BS
among female ballet students. Journal of (2005). Fractured identities: injury and the
Dance Medicine and Science 3(2): 80-83. balletic body. Health 9(1): 49-66.
10. Outerbridge R, Trepman E, Micheli LJ 26. Rietveld B, van de Wiel A (2011). Dance, art
(2002). Ankle instability in children and and top performance sport with specific
adolescents in the unstable ankle. Champaign injuries. Ned Tijdchr Geneeskd. 155(51):
Ill., Human Kinetics. pp 260-269. A4283.
11. Thomas JR and Nelson JK (1996). Research 27. Janev Holcer N, Pucarin-Cvetković J,
methods in physical activity. (3rd Ed.) Mustajbegović J, Zuškin E (2012). Dance as
Canada: Human Kinetics, Chapters 7 and 15. a risk factor for injuries and development of
12. Bronner S, Ojofeitimi S, Rose D (2003). occupational diseases. Art Hig Rada Toksikol
Injuries in a modern dance company: effect 63(2): 239-46.
of comprehensive management on injury 28. Wanke EM, Mill H, Wanke A, Davenport J,
incidence and time loss. The American Koch F, Groneberg DA (2012). Dance floors
Journal of Sports Medicine 31(3): 365-373. as injury risk: analysis and evaluation of
13. Anthony C, Susan A, Pierre A (2002). acute injuries caused by dance floors in
Medical of Performing Artists. Medical professional dance with regard to
Science Sports Exercise 17 (3): 105. preventative aspects. Med Probl Perform Art
14. Eccleston C (2001). Role of psychology in 27(3): 137-142.
pain management. American Journal of 29. Koutedakis, Y (2000). Burnout in Dance: The
Sports Medicine 87:144–152. Physiological Viewpoint. Journal of Dance,
15. Charlotte Lobuno (2001). Musculoskeletal Medicine and Science 4(4): 122-127.
injuries in performing artists. Medical 30. Paparizos AL, Tripp DA, Sullivan MJL,
Science Sports Exercise 81:855-860. Rubenstein ML (2005). Catastrophizing and
16. Logan-Krogstad PM (2006). pain perception in recreational ballet dancers.
Epidemiological study of injuries in J Sport Behav. 28(1): 35-50.
highlander dancers. Electronic Thesis and 31. Encarnacion MLG, Meyers MC, Ryan ND,
Dissertations. Pease DG (2000). Pain coping style ballet
-----[12]-----
performers. J Sport Behav. 23(1): 20-32. dancer. Med Probl Perform Art. 9(1): 7-9.
32. Bowling A (1989). Injuries to dancers: 35. Mainwaring L, Kerr G, Krasnow D (1993).
prevalence, treatment and perceptions of Psychological correlates of dance injuries.
causes. British Medical Journal 298: 731- Med Probl. Perform Art. 8(1): 3-6.
734. 36. Stretanski MF, Weber GJ (2002). Medical
33. Young A, Paul L (2002). Incidence of and rehabilitation issues in classical ballet.
achilles tendon injuries in competitive Am J Phys Med Rehabilitation 81(5):383–91.
highland dancers. Journal of Dance Medicine 37. Clark JE, Scott SG, Mingle M (1989).
and Science 6 (2): 46-49. Viscoelastic shoe insoles: their use in aerobic
34. Krasnow D, Kerr G, Mainwaring L (1994). dancing. Archives Physical Medicine
Psychology of dealing with the injured Rehabilitation 70: 37-40.
-----[13]-----
A STUDY TO EVALUATE THE HEMODYNAMIC RESPONSE TO

REPETITIVE MCKENZIE EXERCISE IN HEALTHY SUBJECTS
Purvi Changela Nandani 1
1. Lecturer, Shri K K Sheth Physiotherapy College, Rajkot
ABSTRACT
BACKGROUND & OBJECTIVES: Low back pain (LBP) is a highly prevalent and disabling conditions worldwide.
Repetitive exercises recommended by McKenzie for the lumbar spine, such as flexion and extension exercises in standing
(FIS and EIS) and lying positions (FIS and EIS) have been used extensively, have cardiovascular effects in people with
no cardiovascular or cardiopulmonary conditions. So the purpose of the study was to examine the hemodynamic response
of stability exercises in normal population, so when these exercises are incorporated in the treatment of LBP, monitoring
can be done for the safety of the individuals.
METHODS: 80 subjects (39= male, 41=female) without cardiovascular or cardiopulmonary disease with mean age of
28.3 ±5.99 years who were representative of people susceptible to low back pain were studied. Subjects were randomly
assigned to 1 of 4 groups, 20 subjects in each, (FIS, EIS, FIL and EIL) were performed sets of 10, 15 and 20 repetitions
of the assigned exercises, with a 15- minutes rest between sets. Pulse rate (PR), Blood Pressure (BP) and Rate pressure
Product (RPP) were recorded after each sets of repetitions.
RESULTS: ANOVA analysis of resting SBP, DBP, PR and RPP for group 1, 2, 3 and 4 before training reveals non-
significant changes. There was a significant difference in SBP, PR and RPP after 15 and 20 repetitions in group 1, 2 and
3 (p< 0.05) while group 4 showed significant changes in DBP along with SBP, PR and RPP after 10, 15 and 20
repetitions. The result showed flexion and extension in lying were more hemodynamically demanding exercises than in
standing. This trend persisted for 15 and 20 repetitions; however at 20 repetitions effects were different
(FIL>EIL>FIS>EIS).
CONCLUSION: Flexion exercises is more stressful than extension (FIL>EIL) in lying. In upright position, flexion is
more stressful than extension (FIS>EIS). After 10 repetitions, McKenzie exercises for “extension in standing” is the least
stressful hemodynamically. These effects may be important with respect to cardiac work, and patient for whom these
exercises are indicated, so these patients should have a cardiac and pulmonary risk factors assessment to determine
whether heart rate and blood pressure should be monitored in them.
KEYWORDS: McKenzie exercises, Hemodynamic Response, RPP, BP
classify patients as having 1 of 3 syndromes

INTRODUCTION (postural, dysfunction, and derangement
syndromes) and to guide treatment. These
Low back pain (LBP) is a common exercises include repeated flexion and extension
condition comprising a major health problem movements performed in different body positions
worldwide1. It is one of the most common as part of a routine lumbar spinal assessment and
musculoskeletal ailments in the general exercise program. McKenzie exercises are
population, affecting approximately 60–80% of successful method for decreasing and
the general population2. It is the most centralizing the pain and increasing spinal
commonest complaint of the working age movements in patients with LBP3.
population which causes a substantial economic The McKenzie exercises involve muscle
burden due to the wide use of medical services and co-contraction to stabilize the trunk and arm
absence from work2. exercise, both of which are associated with
Recently, various literatures have disproportionate cardiovascular demand to a
revealed the most common LBP treatment given load compared with leg work4. Patients with
approaches which include Maitland mobilization, cardiac conditions or high BP are routinely
McKenzie approach, exercises, advice and cautioned about exercises requiring isometric
electrotherapeutic modalities. Therapeutic muscle contractions and arm work, because these
exercises are intended to help to achieve exercises are associated with increased
reconditioning, improved muscle strength and cardiovascular stress as manifested by increased
length, and optimal range of motion. They also work of the heart, which is reflected by increased
indirectly provide pain relief and a better quality heart rate (HR) and BP for a given submaximal
of life2. load compared with leg exercise5.
For 2 decades, lumbar spine exercises The cardiovascular effects of repetitive
advocated by McKenzie for low back pain have McKenzie exercises could have implications for
been used for the management of patients with patients with low back pain who have coexistent
spinal disorders. These exercises are used to cardiovascular conditions. Guidelines for the use
-----[14]-----
of these exercises, however, are typically not EXCLUSION CRITERIA:

accompanied by cautions about potential
cardiovascular stress. Thus, understanding the 1. Subjects with recent episode of back ache
cardiovascular responses to McKenzie exercises 2. History of any cardiovascular,
can be useful for clinicians using these exercises musculoskeletal, neurological problem
for diagnostic purposes and as an intervention5. 3. History of smoking
Several researchers have investigated the 4. Subjects with regular participation in any
effect of various types of submaximal work athletic activity
performed by the upper extremities on the RPP 5. Anemia
versus the lower extremities6. The increase in HR 6. History of metabolic disorders
and systolic BP per unit of increase in work is
greater during upper-extremity exercise than TESTING PROCEDURE:
during lower-extremity exercise. Isometric To examine the cardiovascular effects of
exercise has been shown to increase both HR and the 4 exercise groups, subjects were randomly
BP and, therefore, RPP. Increases in HR and BP assigned in blocks so that each group consisted of
are proportional to the torque produced by the 20 subjects. The exercise groups were designated
muscles7. Lumbar spinal flexion and extension as flexion in standing (FIS), extension in standing
involve upper-extremity work using both (EIS), flexion in lying (FIL), and extension in
concentric and eccentric contractions. Eccentric lying (EIL).
muscle contractions are associated with less The experimental protocol was based on
oxygen demand than concentric muscle established clinical standards for performing
contractions8. repetitive exercises of the lumbar spine as
To our knowledge, there are very less advocated by McKenzie9.
studies of the cardiovascular effects of repetitive Prior to testing, the height, weight and BMI of
McKenzie exercises. The aim of our study, each subject were recorded.
therefore, was to examine the cardiovascular Subjects were instructed not to eat an hour before
effects of 4 common McKenzie exercises i.e. and not to wear tight clothes.
lumbar spinal flexion and extension in standing Subject were instructed not to hold breath during
and lying—when these exercises are repeated 10, exercise.
15, and 20 times. We hypothesized that repetitive Subjects become familiar with 1 of the 4 exercise
McKenzie exercises of the lumbar spine would by verbal instruction, demonstration, and
produce marked changes in the work of the heart practice, before being instructed to perform the
and that these effects increase with multiple exercise for 3 sets of consecutive repetitions
repetitions. (10, 15, and 20 repetitions)7.
During the 15-minute rest period between
METHODOLOGY exercise sets, cardiovascular measurements were
recorded until they returned to baseline. The PR
Sampling: Simple Random Sampling and BP data were used to calculate the RPP after
Study design: Cross-sectional study each set of repetitions (multiply PR and arterial
Sample size: The study was conducted on 80 systolic BP and then multiplying the product by
healthy males and females volunteers between 10-2) 7.
age group of 20-40 yrs. Subjects were taken from After each set was completed and the subject
around Rajkot on the basis of random sampling. returned to the reference position (within 30
Prior to the participation all subjects were seconds), the tester recorded pulse rate (PR) and
explained briefly about the aims and objectives of blood pressure (BP). The mean of 2 measurements
the study, health benefits of the exercises and of PR and BP were obtained from each subject
about the procedure of measuring pulse rate, after each set10.
blood pressure. All subjects were screened and a The same protocol was repeated after the sets
detail medical history was taken to exclude any of 15 and 20 repetitions of the assigned
serious illness. Health screening tool exercise.
questionnaire (AACVPR) was used to identify
the serious illness in the subject. Informed MEASUREMENT PROCEDURE:
consent was signed for their voluntary
The subject was seated in a relaxed
participation.
position in a firm armchair for 5 minutes, during
INCLUSION CRITERIA: which time a questionnaire was completed and
the consent form was reviewed and signed.
1. Age: 20-40 years. The reference position, in which PR and
2. Healthy male and female were included. BP were recorded, was sitting in a chair. BP was
obtained with a sphygmomanometer applied to
-----[15]-----
the left arm. Cuff width, position, tightness, and and pull them towards the chest till they feel
deflation rate were controlled in accordance with comfortable stretch across the low back. Hold the
American Heart Association standards to position for 1-2 seconds and release the knees and
maximize the validity (i.e. agreement with intra- allow the feet to rest back on the ground.
arterial measurements, reliability of the GROUP D: EXTENSION IN LYING 9
measurements) 11.
It was tested by asking the subject to lie
GROUP A: FLEXION IN STANDING 9 in prone position and extend the lumbar spine by
It was tested by asking the subjects to pushing up on hands by extending the elbows.
bend forward (toe touching) from stride standing Subjects were instructed to perform
without bending his/her knees and maintain the exercise for 3 sets of consecutive repetitions (10,
position for 1 to 2 seconds. 15 and 20 repetitions) and take rest for 15 minutes
GROUP B: EXTENSION IN STANDING 9 after each sets to ensure that their HR and BP
returned to resting levels prior to performing the
It was tested by asking the subject to next sets of exercises. SBP, DBP, PR, RPP were
band backward in standing position by keeping measured at before exercise, after 10, 15 and 20
hands on either side of waist. repetition of exercise.
GROUP C: FLEXION IN LYING 9
It was tested by asking the subject to lie
on his/her back with both feet flat on the ground.
Asked the subjects to grasp the front of both knees
RESULTS
TABLE 3: GENDER PROPOSITION
TABLE 1: DISTRIBUTION OF DIFFERENT No of Subject Percent (%)
AGE GROUPS Male 39 48.8
Female 41 51.3
Total 80 100.0
TABLE 4: MEAN SCORES OF SBP, DBP, PR

AND RPP
Baseli After After After
ne 10 rep 15 rep 20 rep
Group-1 ( FIS ) SBP 111.6 113.8 125.2 137.2

Group-2 ( EIS )SBP 117.35 114.6 129.2 120.7
Group-3 ( FIL ) SBP 114.7 125.9 140.2 151.8
Group-4 ( EIL ) SBP 113.4 119.2 134.2 147
Group-1 ( FIS ) DBP 79.5 79.3 82 82.8
Group-2 ( EIS )DBP 80.3 85.4 83.4 83.8
Group-3 ( FIL ) DBP 79.4 79.9 83.9 87.1
Group-4 ( EIL ) DBP 77.9 78.8 82.3 78.6
Group-1 ( FIS ) PR 77.4 85.7 89.5 91.7
TABLE 2: MEAN AGE Group-2 ( EIS ) PR 78.9 85.4 78.5 79
Total number of subjects 80 Group-3 ( FIL ) PR 79 87.8 100.3 145.2
Mean 28.3000 Group-4 ( EIL ) PR 78.1 89.2 98.9 111.6
Std. Deviation 5.99029 Group-1 ( FIS ) RPP 86.02 97.23 112.5 126.06
Minimum (Age) 20.00 Group-2 ( EIS ) RPP 92.03 91.26 101.5 95.27
Maximum (Age) 40.00 Group-3 ( FIL ) RPP 90.33 110.45 140.92 219.78
Group-4 ( EIL ) RPP 88.53 106.22 132.77 160.70
-----[16]-----
TABLE 5 COMPARISON OF SBP, DBP, PR AND RPP AFTER 10, 15 AND 20 REPETITION BETWEEN
GROUP 1, 2, 3 AND 4
TABLE 6: MULTIPLE COMPARISONS FOR MEAN DIFFERENCE OF SBP, DBP, PR AND RPP IN GROUP
1 (FLS)
2 (EIS)
-----[17]-----
3 (FIL)
4 (EIL)
TABLE 10: ANOVA ANALYSIS FOR SBP, DBP, PR, RPP BETWEEN GROUP 1, 2, 3 AND 4 AFTER 10
REPETITION
-----[18]-----
REPETITION
REPETITION
FIGURE 1: SHOWS THE COMPARISON OF SBP, DBP, PR AND RPP AFTER 10, 15 AND 20 REPETITION
BETWEEN GROUP 1, 2, 3 AND 4
DISCUSSION exercises after 15 and 20 repetition in Group 1

(p< 0.05), while there was no significant
The results of present study support the difference in SBP, DBP, PR and RPP in Group 2
experimental hypothesis that there was a (p <0.05). Group 3 and Group 4 (p < 0.05)
significant increase in the hemodynamic response showed a significant change in SBP, DBP, PR and
(SBP, PR and RPP) following McKenzie RPP after 10, 15 and 20 repetition.
-----[19]-----
Repetitive McKenzie exercises, when muscle mass of the upper and lower extremities,
performed, place the cardiovascular system at a the abdominal muscles, and the trunk muscles;
greater stress than normal exercises. The result of therefore, which increases the demand for
study supports the idea with the study done by oxygen to contracting muscles. Consequently,
Saud Al-Qbaidi et al (2001) 9 which documented the HR, BP, CO, and SV were also increased12.
that repetitive McKenzie exercises for the In the present study, subjects
lumbar spine used in management of LBP have performed exercise for 3 sets of consecutive
cardiovascular effects in people with no repetitions (10, 15, and 20 repetitions) with rested
cardiovascular or cardiopulmonary conditions and for 15 minutes after each set to ensure that their
shows the significant increase in HR and SBP. PR and BP returned to resting levels prior to
It has already been proved by many studies that performing the next set of repetitions.
some risk factors associated with back pain like Results of present study strongly support
obesity, smoking, increased serum lipids and the idea that physical therapists should consider
arteriosclerosis have found a strong co-relation monitoring the cardiovascular status of patients
for developing cardiovascular diseases. These with spinal problems for which McKenzie
effects were greater with increased numbers of exercises are indicated and hemodynamic
repetitions. responses also should be considered when they are
One-way ANOVA analysis for SBP, prescribed for home exercise program.
DBP, PR, and RPP after 10 repetition in between
Group 1, 2, 3 and 4 was done. The F value showed CONCLUSION
significant difference in DBP (F= .076) but
there is no significant difference in SBP, PR and  Hemodynamic response were greater after
RPP i.e. F= .449, .494, .578 respectively (p< 20 repetitions of each of the 4 exercises.
0.05). One-way ANOVA analysis after 15  In lying position, flexion is more stressful
repetition shows significant difference in PR i.e. than extension (FIL>EIL).
F= .053 but no significant difference in SBP,
 In upright position, flexion is more stressful
DBP and RPP i.e. F = 0 .079, 0 .218, 0.511
than extension (FIS>EIS).
respectively (p< 0.05). After 20 repetition, there is
 After 10 repetition McKenzie exercise of
a significant difference in SBP, PR and RP i.e. F=
“EIS” is the least stressful hemodynamically.
.015, .000 and .004 respectively.
A study done by Jovarka et al.,
(2002) explains the possible mechanism behind REFERENCES
increase in the cardiovascular parameters.
During exercise, cardiovascular parameters 1. Leo A. M. Elder, Alex Burdouf. Prevalence,
change to supply oxygen to working muscles Incidence, and Recurrence of Low Back Pain
and to preserve perfusion of vital organs. The in Scaffolders During a 3-Year Follow-up
vascular resistance and HR are controlled Study. Spine. 2004;29:101-6.
differently during physical activity. At the onset 2. Praneet Pensri , Nadine E foster ,Surasak
of exercise HR elevation is mediated mostly by Srisuk, G David Baxter ,Suzanne M Mc
central command signals via vagal withdrawal. Donough. Physiotherapy management of low
As work intensity increases and HR approaches back pain in Thailand; A study of
100 beats min, sympathetic activity begins to rise, practice physiotherapy research international.
and further increasing HR was found10. 2005 ;10:201-12.
The study done by CLM Forjaz et al., 3. Luciana Andrade Carneiro Machado,
(1998)11 shows that increased RPP is an indicator Marcelo Von Sperling De Souza,Paulo
of increased myocardial oxygen demand which Henrique Ferreira, Manuela Loureiro
supports the concept of our study that the Ferreira. The McKenzie Method for Low
product of SBP and HR is well correlated to Back Pain. A systematic review of the
myocardial oxygen consumption in young literature with a meta-analysis approach.
healthy subjects as well as in cardiac patient. Spine 2006; 31:254-62.
Cardiovascular demands were greater after 20 4. Astrand PO, Saltin B. Maximal oxygen
repetitions of each of the 4 exercises, with the uptake and heart rate in various types of
demands of the exercises increasing to a muscle activity. J Appl Physiol.
greater extent in lying positions (FIL>EIL) than 1961;16:977–83.
in upright positions (FIS>EIS). 5. MacMasters WA, Harned DJ, Duncan PW.
Both FIL and EIL produced increases in Effect of exercise speed on heart rate, systolic
PR, BP, and RPP following 15 and 20 repetitions blood pressure, and rate-pressure product
of exercise. This can be explained by study of during upper extremity ergometry. Phys
Wayne A. Macmasters et al. (1987) which Ther. 1987;67:1085–8.
showed that FIL involves the work of a large 6. Kispert CP. Clinical measurements to assess
-----[20]-----
cardiopulmonary function. Phys Ther. measurement by indirect cuff

1987;67:1886–90. sphygmomanometry. Am J Hypertension.
7. May GA, Nagle FJ. Changes in rate-pressure 1992;5:207–9.
product with physical training of individuals 11. CLM. forjaz, Y. Matsudaira, FB Rodrigues.
with coronary artery disease. Phys Ther. Post exercises changes in blood pressure
1984;64:1361–6. heart rate and rate pressure product at
8. Dean E. Physiology and therapeutic different exercise intensities in normotensive
implications of negative work: a review. Phys humans. Brazilian journal of physiotherapy.
Ther. 1988;68:233–7. 1998; 31: 1247-55.
9. Saud Al-Qbaidi, Joseph Anthony, Elizabeth 12. Reindl AM, Gotshall RW, Reinke JA.
Dean, Nadia Al-Shuwai. Cardiovascular Cardiovascular response of human subjects to
response to repetitive Mckenzie lumbar spine isometric contraction of large and small
exercises. Phsy ther. 2001; 81:1524-33. muscle groups. Proc Soc Exp Biol Med.
10. Recommendations for routine blood pressure 1977;154:171–4.
-----[21]-----
COMPARISON OF THE EFFECT OF CHAIR RISING EXERCISE AND

ONE-LEG STANDING EXERCISE ON DYNAMIC BODY BALANCE IN
GERIATRICS: AN EXPERIMENTAL STUDY
Kajal Chauhan1, Megha Sheth2, Neeta Vyas3
1 Post Graduate Student, S.B.B. College of Physiotherapy, Ahmedabad
2 Lecturer, S.B.B. College of Physiotherapy, Ahmedabad
3 Principal, S.B.B. College of Physiotherapy, Ahmedabad
ABSTRACT
INTRODUCTION: The impairment of muscle strength and muscle power of the lower extremities, balance/postural
control and walking ability have been recognized as important risk factors for falls. These parameters are known to
become progressively more impaired with aging, increasing the risk of falls among the elderly. A one-leg standing
exercise, in terms of static body balance training, is useful for improving body balance. Chair-rising exercise may
improve muscle power and also body balance. The objective of this study was to compare the effects of chair rising
exercise and one-leg standing exercise in improving dynamic body balance in geriatric subjects.
METHOD: An experimental study was set as home based exercises. 30 subjects (10 males and 20 females) with mean
age of 66.4 years were randomly divided into 2 groups: Chair-rising exercise (CR) group and One-leg standing (OLS)
exercise group. All participants performed calisthenics of the major muscles, tandem gait exercise, and stepping exercise
and as per the group, chair rising and one leg standing. Exercises were performed 3 times per week for 3 weeks. Chair
rising time, one leg standing time, 3m tandem gait time, Timed up and go (3m), 5m walk time were evaluated at baseline
and at the end of 3 weeks.
RESULT: Chair rising time, one-leg standing time, timed up & go, tandem gait time and walking time improved
significantly from the baseline value in the CR group (p=0.0003, p=0.0039, p<0.0001, p=0.0007, p <0.0001
respectively). One leg standing, tandem gait time and walking time improved significantly from the baseline value in the
OLS group (p=0.0455, p=0.0159 and p=0.0025 respectively). The improvements in chair-rising time, walking time and
3m tandem gait time were significantly greater in the chair rising exercise group than in the one-leg standing exercise
group (p=0.015, p=0.0269 p=0.0001 respectively).
CONCLUSION: The chair-rising exercise is more effective than the one-leg standing exercise for improving dynamic
body balance in geriatrics.
KEYWORDS: Chair rising exercise, One leg standing exercise, Body Balance, Geriatric
INTRODUCTION and disabling conditions2. Thus, exercise aimed at

improving physical function must be initiated as
Aging is a process of growing old which early as possible after 60 years of age.
describes a wide array of physiological changes in The impairment of muscle strength and
the body system. Falls are a common problem muscle power of the lower extremities,
among elderly people. Fall is often defined as a balance/postural control, and walking ability has
situation in which the older adult falls to the been recognized as important risk factors for
ground or is found lying on the ground. Fall is an falls3. These parameters are known to become
unintentional loss of balance that leads to failure progressively more impaired with aging4,
of postural stability1. increasing the risk of falls among the elderly.
Fall-related injuries, including head Muscle strength of the lower extremities, balance,
injuries and fractures, are serious problems among and walking ability can be improved with
the elderly, as they often lead to prolonged or even appropriate exercise5.
permanent disability. Thus, the prevention of falls Muscle strength should be distinguished
and, therefore, of the injuries associated with them from muscle power; muscle strength is defined as
would reduce disability, improve quality of life, the maximal force that a muscle can produce
and reduce the costs of health care. against a given resistance, while muscle power
American College of Sports Medicine (force x velocity) is defined as the product of force
position stand have shown that although no and speed3,6. The former is related to bone
amount of physical activity can stop the biological strength, whereas the latter is related to falling4-8.
aging process, there is evidence that regular Thus, the improvement of muscle power, rather
exercise can minimize the physiological effects of than muscle strength, is likely to be important for
an otherwise sedentary lifestyle and increase preventing falls.
active life expectancy by limiting the Various exercises are used to improve
development and progression of chronic disease balance. A one-leg standing exercise, may
-----[22]-----
improve balance in terms of static body balance is times), and the 3-m tandem gait time was each
reportedly useful for reducing the cumulative determined by obtaining the mean value of two
number of falls among the elderly9. Chair-rising measurements. The one leg standing time was
exercise may improve muscle power, and also determined by obtaining the mean value for the
dynamic body balance. Both exercise regimens right and left sides13.
may be utilized in combination for fall-prevention Exercise program
exercise programs10. An intervention study was
therefore conducted with the aim to compare the The daily exercise program consisted of
effect of one-leg standing and chair-rising a one-leg standing exercise (1 min or as much as
exercises on body balance in geriatric subjects. possible x 3 sets on each leg per day) in the OLS
group and a chair-rising exercise (10 times x 3 sets
per day) in the CR group13.
METHODOLOGY All participants performed exercises for
the back muscles, iliopsoas, hamstrings, and calf
The experimental study was conducted muscles, tandem standing (3 min with each leg
at S.B.B. College of physiotherapy, Ahmedabad. forward x 2 sets), a tandem gait exercise (10 steps
The inclusion criteria were both males and x 5 sets), and a stepping exercise (in which the
females between the age of 60-75 years, a fully subject stepped forward, back, to the right, and to
ambulatory status without aids and the ability to the left x 10 times for each step) per day10, 13. All
perform the parameters described below as the exercises were performed three days per week
outcome measures. The exclusion criteria were and required about 30 minutes to perform. The
the use of vitamin D3 supplements for guidelines of the French Society of Geriatrics and
osteoporosis11, gait disturbance requiring an Gerontology recommend rehabilitation exercises
ambulatory aid, a severely rounded back because with a professional to extend the rehabilitation
of osteoporosis, an acute disease phase, and severe benefits14. Thus, one session per week was
cardiovascular disease. Thirty ambulatory supervised by the physical therapist, and the other
subjects (10 men and 20 women) were recruited two sessions were performed at home under
in this study. They were given information about family supervision. All the participants were
the study and written informed consent was given written exercise protocol in understandable
obtained from the subjects prior to the study. language to perform at home for 2 sessions13.
Level of significance was kept at 5%.
STATISTICAL ANALYSIS AND
PROCEDURE
RESULTS
Subjects were randomly divided into two
Data was analysed using graph pad
groups (n=15 in each group): Chair-rising
prism. The mean age of the participants was 66.4
exercise group (CR group) and one-leg standing
years. Data are expressed as the means ± SD. No
exercise group (OLS group). Outcome measures
significant differences in any parameters at
were taken at baseline and in the end at 3 weeks.
baseline were observed between the two groups.
Physical function and balance were evaluated by
Table 1 shows the demographic characteristics of
measuring the 5-m walking time, timed up & go
the subjects.
(3 m), the chair-rising time (5 times), the one-leg
standing time, and the 3-m tandem gait time1.
TABLE 1: BASELINE CHARACTERISTICS OF
Chair-rising time (5 repetitions of rising from a STUDY SUBJECTS
chair as quickly as possible with arms crossed
CR OLS
over the chest) is an index of muscle power3. The
Gender: Male; 4 males; 6 males; 9
one-leg standing time12 is an index of static body Female/ total 11females /15 females /15
balance. The tandem gait time is an index of Age (years) 67.06 ± 4.9 65.86 ± 4.8
dynamic body balance. The 5- m walking time, CR: chair rising exercise group, OLS: one-leg standing exercise
group
the timed up & go (3 m), the chair-rising time (5
TABLE 2: PRE AND POST MEANS± SD AND P VALUE IN CR AND OLS GROUPS
CHAIR RISING GROUP ONE LEG STANDING GROUP
Baseline Endpoint p value Baseline Endpoint p value
Chair rising time 15.32 ±5.72 13.42±4.62 0.0003 14.09 ±7.01 18.83 ±6.59 0.1290
One-leg standing time 5.79 ± 3.0 8.37±4.28 0.0039 6.92 ±4.85 8.07 ±5.14 0.0455
Timed up & go (3 m) 14.47 ±5.79 12.80±5.52 <0.0001 15.707 ±6.32 13.79 ±6.80 0.3389
3-m tandem gait time 17.90 ±4.71 12.80±5.52 0.0007 17.59 ±1.53 16.22 ±1.92 0.0159
5-m walking time 11.34 ±3.08 8.48±2.71 <0.0001 11.34 ±3.08 8.48±2.71 0.0025
-----[23]-----
Paired t test was used for analysis within significant but more in CR group. So it shows that
the groups. Difference in means in chair rising one leg standing exercise and chair rising exercise
time, one leg standing time, timed up and go, 3m improves static body balance. CR group shows
tandem gait time and 5m walking time in CR better results than OLS group in one leg standing
group and one leg standing time, 3m tandem gait time because of effect of chair rising exercise on
time and 5m walking time in OLS group showed muscle power which is required in one leg
significant results. standing.
Timed up and go which mainly consists
TABLE 3: DIFFERENCE IN MEANS BETWEEN of chair-rising, walking, turning, and sitting, is
GROUPS known to be a reliable and valid test for
Means ± SD U value p value quantifying functional mobility17 showed
Physical function
CR OLS statistically significant improvement in CR group
Chair rising time 1.94± 1.67 0.29± 0.28 40.5 0.0015 and no significant results in OLS group. Timed up
One-leg standing time 2.61± 3.18 1.65±1.24 110 0.4669 and go is an index of muscle power and dynamic
Timed up & go (3 m) 2.44 ± 3.79 1.8± 0.74 73 0.052
3-m tandem gait time 3.77± 4.18 2.32± 3.9 65.5 0.0269 body balance. Yamashita F et al concluded that
5-m walking time 2.85± 1.49 0.95± 0.55 23 0.0001 after 5-months exercise program, the timed up &
go, one-leg standing time, and tandem gait time
DISCUSSION improved significantly in the one-leg standing
exercise group, while the walking time and chair-
Data analysis within groups showed that rising time in addition to above parameters
chair rising time, one-leg standing time, timed up improved significantly in the chair-rising exercise
& go, tandem gait time and walking time group. The improvements in the walking time,
improved significantly from the baseline value in chair-rising time, and tandem gait time were
the CR group (p=0.0003, p=0.0039, p<0.0001, p= significantly greater in the chair rising exercise
0.0007, p <0.0001 respectively). One leg standing group than in the one-leg standing exercise group.
group showed significant improvement in one leg The present study showed that the chair-rising
standing time, 3m tandem walk time and 5m walk exercise was more effective than the one-leg
time (p=0.0455, p=0.0159 and p=0.0025 standing exercise for improving walking velocity
respectively). Between group results showed and dynamic body balance13.
improvements in chair-rising time, walking time 3m tandem gait time showed statistically
and 3m tandem gait time were significantly significant difference in OLS group. CR showed
greater in the chair rising exercise group than in greater improvement than OLS group due to
the one-leg standing exercise group (p=0.015, improvement on dynamic body balance. One leg
p=0.0269 p=0.0001 respectively). standing exercise showed improvement due to
Chair rising time was significantly static body balance which is required to maintain
improved from baseline in chair rising group but the body position in tandem stance.
was insignificant in one leg standing group. Difference in 5m walk time was
According to Yamshita F, chair-rising exercise statistically highly significant in CR and OLS
may train the quadriceps and gluteus medius groups. Walking requires dynamic body balance
muscles and improve joint movement of the lower so showed greater improvement in CR than OLS
extremities, possibly improving body balance. group.
Whereas one leg standing exercise only improves Jacobson et al reported that a static
static body balance so there was no change in balance exercise resulted in the improvement of
chair rising time in one leg standing group13. the 30-sec chair test repetition, the 8-foot up and
Sherrington C concluded that balance training go test, balance assessments, and leg function in
which contained a higher dose of exercise, and did frail elderly individuals (18). Kuptniratsaikul et al
not include walking training had the greatest also reported that a simple balancing exercise
effect on reducing falls. Exercise aimed at improved the timed up & go and chair stand in
improving not only body balance but also muscle elderly patients with a history of frequent falls19.
power is important for preventing falls15. The one- During one leg standing exercise, due to
leg standing exercise is a static body balance fear of falling, muscle weakness and poor balance,
training method, while the chair-rising exercise is patients tend to take support and only lack of
a muscle power training method, both of which support improves balance. Whereas, chair rising
were convenient and well tolerated in subjects exercise are safer than one leg standing exercise
with locomotive disorders. In particular, muscle and helps in improving muscle power as well as
power, as evaluated using the chair-rising test, dynamic body balance. Along with chair rising
plays a crucial role in the aging process16. exercise, tandem walking, active movements of
One leg standing time is an index of lower limb can give beneficial effects in
static body balance. In CR group and OLS group, improving functions in geriatrics.
one leg standing time improvement was
-----[24]-----
In geriatrics, it is important to reduce fear 2011; 14:489-95.

of fall and prevent fall related injuries. So chair 6. Runge M, Hunter G. Determinants of
rising exercise are beneficial in geriatrics to musculoskeletal frailty and the risk of falls in
reduce falls and improve dynamic body balance old age. J Musculoskel Neuronal Interact
and muscle power. This exercise can be 2006; 6:167-73.
performed at home with less or no supervision. 7. Frost HM. Defining osteopenias and
Whereas, one leg standing exercise is beneficial in osteoporosis: another view (with insights
improving static body balance. So one leg from a new paradigm). Bone 1997; 20:385-
standing exercise can be included in an exercise 91.
program to improve balance. 8. Schiessl H, Frost HM, Jee WSS. Estrogen and
bone-muscle strength and mass relationship.
LIMITATIONS Bone 1998; 22:1-6.
9. Sakamoto K, Nakamura T, Hagino H, Endo
Long term follow up was not taken. N, Mori S, Muto Y, Harada A, Nakano T, Itoi
E, Yoshimura M, Norimatsu H, Yamamoto
H, Ochi T; Committee on Osteoporosis of
CONCLUSION The Japanese Orthopaedic Association.
Effects of unipedal standing balance exercise
Chair rising group shows more on the prevention of falls and hip fracture
improvement than one-leg standing group in among clinically defined high risk elderly
walking time, tandem gait time and chair rising individuals: a randomized controlled trial. J
time. So chair-rising exercise may be more Orthop Sci 2006; 11:467-72.
effective than the one-leg standing exercise for 10. Iwamoto J, Suzuki H, Tanaka K, Kumakubo
improving dynamic body balance in geriatrics and T, Hirabayashi H, Miyazaki Y, Sato Y,
may reduce fall related injuries. Takeda T, Matsumoto H. Preventative effect
of exercise against falls in the elderly: a
CLINICAL IMPLICATION randomized controlled trial. Osteoporos Int
2009; 20:1233-40.
Chair rising exercise is well tolerated and 11. Dukas L, Schacht E, Runge M, Ringe JD.
has no adverse effects as was observed during this Effect of a six month therapy with
exercise program, suggesting the usefulness and alfacalcidol on muscle power and balance and
convenience of physical function as well as it may the number of fallers and falls. Arzneimittel
be helpful in improving muscle power which is for schung 2010; 60:519-25
needful in normal activities. 12. One-Legged (Single Limb) Stance Test
ETHICS APPROVAL: Study was Posted on: February 27, 2006 Vol. 17, Issue
approved by Institutional Ethics Committee of 6 : Page 10 Geriatric Function By Carole
S.B.B. College of physiotherapy, Ahmadabad. Lewis, PhD, PT, MSG, MPA, GCS, and
Ethical Approval no. PTC/IEC/29/2012-13. Keiba Shaw, MPT, MA, EdD.
13. F. Yamashita, J. Iwamoto, T. Osugi, M.
REFERENCES Yamazaki, M. Takakuwa3Chair rising
exercise is more effective than one-leg
1. Geriatric physical therapy. 3rd edition. standing exercise in improving dynamic body
Andrew A. Guccione, Rita A. Wong, Dale balance: A randomized controlled trial J
Avers. Ch 18, pg 331, 343-45. http:/ Musculoskelet Neuronal Interact 2012;
evolve.elsevier.com 12(2):74-79.
2. Chodzko-Zajko WJ, Proctor DN, Fiatarone 14. Beauchet O, Dubost V, Revel Delhom C,
Singh MA, Minson CT, Nigg CR, Salem GJ, Berrut G, Belmin J; French Society of
Skinner JS. American College of Sports Geriatrics and Gerontology. How to manage
Medicine position stand. Exercise and recurrent falls in clinical practice: guidelines
physical activity for older adults. Med Sci of the French Society of Geriatrics and
Sports Exerc 2009; 41:1510-30. Gerontology. J Nutr Health Aging 2011;
3. Runge M, Rehfeld G, Resnicek E. Balance 15:79-84.
training and exercise in geriatric patients. J 15. Sherrington C, Tiedemann A, Fairhall N,
Musculoskel Neuronal Interact 2001; 1:61-5. Close JC, Lord SR. Exercise to prevent falls
4. Asmussen E. Aging and exercise. Environ in older adults: an updated meta-analysis and
Physiol 1980; 3:419-28. best practice recommendations. N S W Public
5. Tiedemann A, Sherrington C, Close JC, Lord Health Bull 2011; 22:78-83.
SR. Exercise and Sports Science Australia 16. Runge M, Rittweger J, Russo CR, Schiessl H,
position statement on exercise and falls Felsenberg D. Is muscle power output a key
prevention in older people. J Sci Med Sport factor in the age related decline in physical
-----[25]-----
performance? A comparison of muscle cross functional capacity in communitydwelling

section, chair-rising test and jumping power. elderly people: a randomized controlled trial.
Clin Physiol Funct Imaging 2004; 24:335-40. Clin Rehabil 2011; 25:549-56.
17. Podsiadlo D, Richardson S. The timed “Up & 19. Kuptniratsaikul V, Praditsuwan R,
Go”: A test of basic functional mobility for Assantachai P, Ploypetch T, Udompunturak
frail elderly persons. J Am Geriatr Soc 1991; S, Pooliam J. Effectiveness of simple
39:142-8. balancing training program in elderly patients
18. Jacobson BH, Thompson B, Wallace T, with history of frequent falls. Clin Interv
Brown L, Rial C. Independent static balance Aging 2011; 6:111-7.
training contributes to increased stability and
-----[26]-----
A STUDY TO FIND OUT THE CORRELATION BETWEEN HANDGRIP

STRENGTH AND HAND SPAN AMONGST HEALTHY ADULT MALE
Nandani Milin1
1. Junior Lecturer, Shri K K Sheth Physiotherapy College, Rajkot
ABSTRACT
BACKGROUND: Grip strength is widely accepted indicator of nutritional status, bone mineral content, muscular
strength and functional integrity of upper extremity. The assessment of grip strength plays a vital role in determining the
efficacy of different treatment strategies of hand. In all hand anthropometric variables, hand span and grip span play
important role in hand as it is used in various manipulative skill such as gross and prehension activity. Since men are the
most important source of work force, their hand grip strength and anthropometric data are essential for ergonomic
considerations, so present study has been undertaken to generate hand grip strength and hand span of healthy adult
men to determine whether these parameters are correlated.
METHODOLOGY: 120 healthy adult male with age group between 18-35 years were selected. Subjects were divided
into two groups 18 to 26 years and 27 to 35 years by simple random sampling. The hand span of dominant hand was
measured with measure tape from tip of the thumb to tip of little finger and grip strength was measured using Jamar
Hand Dynamometer.
RESULTS: The data was analyzed by Pearson’s correlation coefficients to correlate hand span and grip strength in
healthy adult male which showed positive correlation (r =0.794, p<0.05).Unpaired t test was done to compare the hand
span and grip strength in age group of 18-26 years and 27-35 years which showed significant difference between hand
span (t = 3.244, p <0.05) and grip strength (t=4.794, p <0.05).
CONCLUSION: There is a significant positive correlation between hand span and hand grip strength in healthy adult
male.
KEY WORDS: Hand span, Hand grip strength, Grip span, Jamar Dynamometer
INTRODUCTION assessment measure grip strength has been shown

to have predictive validity and low values are
Grip strength is often used as an associated with falls, disability, impaired health-
indicator of overall physical strength, hand and related quality of life.
forearm muscles performances, as a functional Hand grip strength is widely used test in
index of nutritional status and physical experimental and epidemiologic studies in young
performance1. The assessment of grip strength healthy individuals. Hand span is correlated with
plays a cardinal role in hand rehabilitation1. It grip span. Hand grip strength is influenced by
evaluates the patient’s initial limitation and hand span, which implies the need for adjustment
renders a rapid reassessment of patient’s of the grip span of hand dynamometer to the hand
improvement throughout the rehabilitation2. It is span. So there will be adjustment of grip span
also recommended as a good simple measure of during the grip strengthening exercise according
muscle strength when ‘measured in standard to hand size9.
conditions’ and plays a vital role in determining Grip strength measurement have a
the efficacy of different treatment strategies of variety of clinical implication such as assessment
hand3. of general strength in order to determine work
Hand grip strength is a physiological capacity, the extent of injury and diseases process
variable that is affected by a number of factors and the potentials for the progress for the
including hand size/ hand span4, age, gender, rehabilitation2. Grip strength measurement is used
different angle of shoulder, elbow, forearm, and in the investigation and the follow up of the
wrist5, posture6, grip span, muscle length patients with the neuromuscular disease1. Several
insertion, angle of tendon at time of contraction, studies have examined the relationships
nutritional status, BMI7, fatigue, hand dominance, between hand grip strength and hand span, but
time of day, pain, cooperation of the patient and information related to the correlations of
presence of amputation, restricted motion, handgrip strength and hand span are limited, So
sensory loss, hip/waist circumference, body size, the present study was conducted to find out the
arm and calf circumferences, various correlation between hand span and handgrip
subcutaneous skin folds, a range of functional strength amongst healthy adult male since men are
ability variables, rotator cuff weakness8. the most important source of work force in
Longitudinal studies confirm that grip strength India, their hand grip strength and
declines after midlife, with loss accelerating with anthropometric data are essential for ergonomic
increasing age and through old age. As an considerations.
-----[27]-----
METHODOLOGY extended between 0°- 30° & ulnarly deviated

15°. The subject alternatively grips the
Study Design: Cross-sectional dynamometer with his dominant and non-
observational study dominant hands, performing 3 trials, using
Sampling Technique: Simple Random different grip spans in random order, allowing
Sampling a 1-minute rest between the measurements.
Study Setting: Various Industries In and
Around Rajkot
Sample Size: The study was conducted
on 120 healthy adult male with age group of 18 -
35 years who were selected by Random Sampling
Techniques. The proposed title and procedure was
being approved by ethical committee members,
subjects were selected who fulfilled the inclusion
and exclusion criteria, the details and purpose of
the study were explained to all subjects for
maximum co-operation and written consent was FIGURE 1: MEASUREMENT OF HAND SPAN
taken from them. All Participants were assessed
for hand span and hand grip strength.
INCLUSION CRITERIA:
 Age: 18-35years
 Healthy adult male were participated
EXCLUSION CRITERIA
 Subjects with any upper limb and hand
injuries
 Any pathological condition of Upper
Extremity
 Subjects who participated in sports FIGURE 2: MEASUREMENT OF GRIP
 Any neurological impairments of upper limb STRENGTH
 Any traumatic condition in past 6 months
 History of metabolic disorders RESULTS
 Uncooperative subjects
 Measurement Procedure : TABLE 1: DESCRIPTIVE ANALYSIS FOR
DIFFERENT AGE GROUP
Before starting the test, all the subjects
were oriented towards the study and were given a Age Group Mean SD
detailed theoretical explanation of how to perform 18-26year 20.768 +2.51551
27-35year 24.667 +3.71842
the test followed by practical demonstration of
how to perform the test.
TABLE 2: GENDER PROPOSITION
All subjects were given few trials before
reading was taken till they were clear about the Total Subjects Male Female
120 51 69
procedure and confident to perform the test. All (%) 43% male 57% female
subjects were reassessed and corrected until they
were able to perform without error. TABLE 3: CORRELATION BETWEEN HAND
Measurement of hand span: 10 Hand SPAN AND HAND GRIP STRENGTH IN
span was measured from the tip of the thumb HEALTHY ADULT MALE
to the tip of the small finger with the hand NO VARIABLES MEAN+SD r value p value
opened as wide as possible (Figure 1). 1 Hand span 20.51+1.95 0.794 0.0001**
Hand grip
2 27.28+8.18 0.794 0.0001**
MEASUREMENT OF HAND GRIP strength
r value=0-1 shows moderately positive correlation
STRENGTH10 ** indicates the result is highly significant as p value is <0.0001
Handgrip strength was measured using a

Jamar Hand dynamometer (Figure 2).
Grip strength is tested by placing the subject
in seated position with his arm side, elbow
flexed 90°, forearm in mid-prone position, wrist
-----[28]-----
TABLE 6: COMPARISON OF THE HAND SPAN

60
Hand Grip Strength

AND HAND GRIP STRENGTH BETWEEN AGE
40 GROUP OF 18-26 YEARS AND 27-35 YEARS
20 Varia MEAN+SD t P Res
0 ble 18-26years 27-35years ult
10 15 20 25 Hand 20.2245+1.9 34.5455+4.9 3.2 0.02* S
span 8723 2542 44
Hand Span Hand 4.7 0.000 HS
grip 25.6531+7.8 21.7727+1.1 94 1**
streng 8722 0978
FIGURE 3: CORRELATION BETWEEN HAND th
SPAN AND HAND GRIP STRENGTH IN S = Significant, HS = Highly Significant, ** indicates the result is
HEALTHY ADULT MALE highly significant as p value is <0.0001,
* indicates the result is significant as p value is <0.05
TABLE 4: CORRELATION OF HAND SPAN

AND HAND GRIP STRENGTH IN AGE GROUP Comparison of Hand Grip Strength in Age
OF 18-26 YEARS Group 18-26years and 27-35years
Hand grip strength

NO VARIABLES MEAN+SD r value p value
40
1 Hand span 20.22+1.987 0.763 0.0001**
Handgrip 20
2 25.65+7.887 0.763 0.0001**
strength
r value=0-1 shows moderately positive correlation, ** indicates the 0
result is highly significant as p value is <0.0001 18-26 27-35
50 FIGURE 6: COMPARISON OF HAND GRIP

Hand Grip Strength
40 STRENGTH IN AGE GROUP 18-26YEARS AND

30 27-35YEARS
20
10 DISCUSSION
0
10 15 20 25
Hand Span Hand grip strength is influenced by hand
span, which implies the need for adjustment of the
FIGURE 4: CORRELATION OF HAND SPAN grip span of dynamometer to the hand span. Hand
AND HAND GRIP STRENGTH IN AGE GROUP grip strength is widely used test in experimental
OF 18-26 YEARS and epidemiologic studies in young healthy
individuals. The results of the present study
TABLE 5: CORRELATION OF HAND SPAN supports experimental hypothesis which shows
AND HAND GRIP STRENGTH IN AGE GROUP
OF 27-35 YEARS
positive correlation between hand span and hand
grip strength measured in male industrial workers
NO VARIABLES MEAN+SD r value p value with age group of 18-35 years.
1 Hand span 21.772+1.109 0.869 0.0001** According to Pearson correlation test,
Hand grip
2 34.545+4.925 0.869 0.0001** there is a positive correlation between hand span
strength
r value=0-1 shows moderately positive correlation, ** indicates the and hand grip strength (p<0.001) in healthy adult
result is highly significant as p value is <0.0001
male which is supported by Vanesa España-
Romero et al., (2006)9 who revealed that an
45 optimal grip span to determine the maximum
Hand Grip Strength
40 handgrip strength was identified for both genders

35 may guide clinicians and researchers in selecting
30
the optimal grip span on the hand dynamometer
when measuring grip strength.
25
There is a positive correlation between
20
19 20 21 22 23 24
hand span and hand grip strength in young healthy
Hand Span
individuals because hand span is affected by grip
force, exertional level, maximal grip strength and
submaximal grip strength which is supported by
FIGURE 5: CORRELATION OF HAND SPAN Oh and Radwin (1993)11 who reported that hand
AND HAND GRIP STRENGTH IN AGE GROUP span affects grip strength, grip force, and exertion
OF 27-35 YEARS level.
The comparison of hand span and hand
grip strength between 18-26 years of age and 27-
35 years of age group was done shows significant
difference in hand span and hand grip strength in
both the groups because age is positively
correlated with hand grip strength. With
-----[29]-----
increasing age, the size of the limb gradually person, subjects working in the small scale
increases, the length and width of hand also industries (like diamond workers, silver
increase. smith, imitation jewelry workers, auto parts
In this study it was found that the hand & machinery workers etc.)
grip strength is influenced by hand span and a  Study can be done with different age group.
positive correlation was found between grip  Study can be done with patients with hand
strength and hand span. This finding is in disability to find out the status of hand
agreement with the findings of MacDermid et function.
al (2002)12, where in significant correlations
were noted between hand grip strength and hand CONCLUSION
length, hand breadth and hand span of respective
sides in healthy population. There is positive correlation between
A study showed that the middle grip span hand span and hand grip strength in young healthy
allowed for greater absolute forces than smaller or individuals. There is a significant positive
larger ones. However the association between correlation between hand span and hand grip
hand size and optimal grip span was not analyzed strength in 18-26 years age group and 27-35 years
in the study. Firrell and Crain (1996)13 studied age group.
setting about the dynamometer which produced
maximal grip strength and correlated that setting
with characteristics of the individual. They REFERENCES
reported that the majority of the hands (89%) had
a maximal strength at setting II (of V) of a hand 1. Massey-Westrop N, Rankin W, Ahern M,
dynamometer, whereas no clear significant Krishnan J, Hearn TC. 2004. Measuring grip
correlation between hand size and maximal strength in normal adult: reference ranges
setting was found. and a comparison of electronic and
In this study jamar hand dynamometer hydraulic instruments. J Hand Surg29A: 514-
was used to measure the hand grip strength. Jamar 19.
Hand dynamometer is reliable and valid 2. Mohamed Sherif Sirajudeen, Umama Nisar
instrument for measuring hand grip strength in Shah, Padmakumar Somasekharan Pillai,
young healthy individuals. This is supported by Naajil Mohasin, Manjula Shantaram.
Mathiowetz V. (2002) 14 who found that Jamar Correlation between Grip Strength and
Hand dynamometer have stronger concurrent Physical Factors in Men. International
validity (r=0.9994) and excellent inter-instrument Journal of Health and Rehabilitation
reliability (0.90-0.97). Sciences.Oct 2012 : 1 (2).
A research reveals that a Dominant hand 3. Navdeep Kaur and Shyamal Koley An
is approximately 10% stronger than the non Association of Nutritional Status and Hand
dominant hand. Thus in this study the subjects Grip Strength in Female Labourers of North
hand grip strength and hand span was taken for India. Anthropologist 2010,12(4): 237-43.
dominant hand. A supported study was 4. Harkonen R, Piirtomaa M, Alaranta H. Grip
documented which found that dominant hand is strength and hand position of the
significantly stronger in right handed subjects but dynamometer in 204 Finnish adults. J Hand
no such significant difference between sides could Surg 1993;18B:129 –32
be documented for left handed people15. 5. Su C-Y, Lin JH, Chien TH, Cheng KF, Sung
This study suggests that hand span is YT. Grip strength in different positions of
positively correlated with hand grip strength elbow and shoulder. Arch Phys Med Rehabil
because hand span affects maximal and 1994;75:812– 15.
submaximal handgrip strength and also hand span 6. Mathiowetz V, Rennells C, Donahoe L.
affects grip strength, grip force, and exertion. Effect of elbow position on grip and key
pinch strength. J Hand Surg 1985; 10A:694–
7.
LIMITATION OF THE STUDY 7. Shyamal Koley, Navdeep Kaur and J.S.
Sandhu A Study on Hand Grip Strength in
 Only power grip was tested, precision grip Female Labourers of Jalandhar, Punjab,
was not tested. India. Journal Life Science.2009; 1(1): 57-62.
 There was no control group in this study. 8. Smith, T, S Smith, M Martin, R Henry, S
 The sample size was unequal in age group of Weeks, A Bryant. Grip strength in relation to
18-26 years and 27-35 years. overall strength and functional capacity in
FURTHER RECOMMENDATION very old and oldest old females. The Haworth
 In future studies, measurement of hand span Press Inc, 2006: 63-78.
and hand grip strength can be taken in sports 9. Vanesa España-Romero, Enrique G. Artero,
-----[30]-----
AlbaM. Santaliestra-Pasias, Angel Gutierrez, 13. Firrell JC, Crain GM. Which setting of the
Manuel J. Castillo, Jonatan R. Ruiz Hand dynamometer provides maximal grip
Span Influences Optimal Grip Span in Boys strength? J Hand Surg 1996;21A: 397–401.
and Girls Aged6 to 12 Years. J Hand Surg 14. Mathiowetz V, Rennells C, Donahoe L.
2008; 33A :378–84. Effect of elbow position on grip and key
10. Hunter JM, Mackin EJ, Callahan AD. pinch strength. J Hand Surg 1985; 10A:694–
Rehabilitation of the hand: Surgery and 7.
therapy. Missouri: Mosby 1995. 15. Nurgul Arinci Incel, Esma Ceceli, Pinar
11. Oh S, Radwin RG. Pistol grip power tool Bakici Durukan, H Rana Erdem, Z Rezan
handle and trigger size effects on grip Yorgancioglu. Grip Strength: Effect of Hand
exertions and operator preferance. Hum Dominance Singapore Med J 2002; 43(5) :
factors. 1993;35:551-69. 234-7.
12. MacDermid JC, Fehr LB, Lindsay KC. The
Effect of Physical Factors on Grip Strength
and Dexterity. Hand Therapy.2002;7:112-
8.
-----[31]-----
AWARENESS AND KNOWLEDGE OF PHYSIOTHERAPYAMONG THE

GENERAL PUBLIC IN AN AFRICAN MARKET IN ACCRA
METROPOLIS, GHANA
Olajide A. Olawale1, Magdaline T. Adjabeng2
1.B.Sc, M.Ed, Ph.D, MNSP, MGAP, Department of Physiotherapy, Faculty of Clinical Sciences, College of
Medicine, University of Lagos, PMB 12003, Lagos, Nigeria
2.B.Sc, MGAP, Physiotherapy Department, Korle Bu Teaching Hospital, PO Box KB 52, Korle Bu, Accra,
Ghana
ABSTRACT
BACKGROUND: Any profession that has a great role to play in the society must have a clear identity with the public
who should demonstrate a high level of awareness of the profession. This study was designed to ascertain the general
public’s awareness of physiotherapy in Accra, Ghana.
METHODOLOGY: Participants were 500 individuals drawn from the general public at Makola market in Accra, Ghana.
They completed a structured questionnaire designed to test knowledge of physiotherapy profession and services provided
by physiotherapists. Response frequencies for the survey questions were collated and displayed in tables, pie charts and
bar charts.
RESULTS: Three hundred and forty-three (343, 68.6%) of the respondents had previous knowledge of physiotherapy as
a profession. The mass media were the main sources of their information, with newspapers reported as the major sources.
Majority of the respondents (229, 66.8%) stated that physiotherapy services can be received in hospitals. Many
respondents shared the view that physiotherapists treat disorders affecting bones and joints (180, 52.8%).
CONCLUSION: Majority of the participants had a high level of awareness of physiotherapy. However, there is still the
need to increase the knowledge by educating the Ghanaian general public on the role and importance of physiotherapy.
KEYWORDS: Awareness, knowledge, physiotherapy, general public.
INTRODUCTION population of 24 million7. These few

physiotherapists provide services either in public
Physiotherapy is an internationally hospitals or private clinics, or in rehabilitation
recognised health profession which may be centres, residential homes, and health spas. The
practiced by qualified and, where required by state monthly records in public hospitals reveal that
or national legislation, duly registered or licensed physiotherapists offer comprehensive care for
physiotherapists only1. It is a dynamic profession patients with diverse medical and surgical
which uses a range of treatment techniques to conditions such as arthritis, burns, pain disorders,
restore movement and function within the body2. paediatrics disorders, pulmonary disorders,
Physiotherapists promote the health and well- neurological disorders, cardiac disorders, trauma,
being of individuals and also prevent and sport injuries.
impairments, functional limitations, and disability Although physiotherapy has a great role
in individuals at risk of altered movement to play in the society, it seems to lack a clear
behaviours due to health or medically related identity with the public who demonstrate limited
factors, socio-economic stressors and lifestyle awareness and understanding of the scope of the
factors3. They also work to combat a broad range profession’s role and have difficulty
of physical problems, in particular those differentiating it from alternate practitioners8,9.
associated with neuromuscular, musculoskeletal, How can the physiotherapy profession be made
cardiovascular and respiratory systems2. known and utilised by the public if a pool of
Physiotherapy is an essential part of health care aspiring profession seekers is not aware of its
delivery system4, and it is practiced independently existence? A number of studies have been
of other health care providers and also within conducted to ascertain the general publics’
inter-disciplinary rehabilitation programmes for awareness and knowledge of physiotherapy10,11.
the restoration of optimal function and quality of The results obtained from these studies may not
life in individuals with loss and disorders of reflect the situation in developing countries
movement (Steins et al 2001; Rothstein 2002)5,6. because of differences in health care systems. In
Physiotherapy is a growing profession in Ghana, there have been several attempts to
Ghana, West Africa, though it was first introduced integrate the profession into the society and raise
into the country in 1944 by a British expatriate. the level of public awareness about
The services are not readily available throughout physiotherapy. The establishment of a 4-year
the country because there are less than 200 undergraduate physiotherapy education
practicing physiotherapists (as at June 2011) for a programme at the University of Ghana in 2001
-----[32]-----
was one of such attempts. This cross-sectional Process of administration of the

descriptive study was undertaken to assess the instrument
level of awareness and knowledge about On each day of data collection, one of the
physiotherapy among the general public in a researchers (MTA) visited stalls and shops in the
typical African market located in Accra market to introduce herself, explain the purpose of
metropolis, Ghana. the study and present the questionnaire to the
respondents. Questionnaires were given to the
AIMS & OBJECTIVES owner / keeper of every 10th shop, who was given
enough time to read the document and give
The main aim of this study was to informed consent to participate. The starting point
ascertain the awareness and knowledge of and direction of movement on each day were
physiotherapy among the general public in a determined at random such that a large part of the
typical African market in Accra, Ghana. market was covered over the 2-month period of
The specific objectives of the study were the study. Each respondent read and completed
to determine the questionnaire while the researcher waited to
(1) knowledge of where physiotherapy collect it.
service can be received (2) knowledge of
DATA ANALYSIS
conditions treated by physiotherapists (3)
knowledge of treatment modalities used in The statistical package used in analysing
physiotherapy and (4) how respondents make use the data was Epi-Info 2002 version. Response
of their knowledge of physiotherapy. frequencies for the survey questions were collated
and displayed in tables, pie charts and bar charts.
METHODOLOGY
RESULTS
Participants for the study were recruited
from a local market place called Makola Market, Demographic characteristics of respondents
which is the largest market in Accra metropolis
A total of 500 respondents comprising
and one of the busiest in West Africa. It occupies
209 (41.8%) men and 291 (58.2%) women
a large part of the Central Business District of
participated in the study. They were aged 20 years
Accra, the capital city of Ghana, and harbours
and above. As seen in Table 1, the highest number
over 10,000 sellers of various commodities
of participants was in the age range of 30-49 years
including clothing, food stuffs, electrical
(54.2%). Very few participants (12 or 2.4%) were
appliances, cosmetics and cooking utensils. Major
in the age group ≥ 70 years.
inclusion criterion was ability to read and
understand the contents of the survey Awareness of Physiotherapy Services
questionnaire. Three hundred and forty three
participants (68.6%) had previous knowledge of
DESCRIPTION OF THE INSTRUMENT physiotherapy services while 157 (31.4%)
Data was collected with a survey participants had no such knowledge. The sources
questionnaire which comprised 20 closed ended of information about physiotherapy services
questions divided into three sections. Section A included information obtained from health
contained questions on the demographic professionals (n=120), newspapers (n=83),
characteristics of the respondents. Sections B and television (n=59), radio (n=43), and other sources
C contained items which evaluated awareness and (n=36) such as relations who benefited from
knowledge of physiotherapy among the public. physiotherapy services (Figure 1). Of the 343
The questionnaire was adapted from previous participants who had previous knowledge of
studies8,10,12. It was deliberately made simple to physiotherapy, 165 (48.1%) were of the opinion
facilitate comprehension due to the assumed low that it is a branch of medicine, 84 (24.5%) thought
literacy level of the participants. Content validity that it is massage, 54 (15.8%) considered it as
was determined by a panel of 5 experienced exercises while 40 (11.7%) expressed the view
clinical and academic physiotherapists. The that it is human body mobilization.
questionnaire was pilot-tested on 20 traders drawn
from another market (Kaneshie market) in Accra.
TABLE 1: DEMOGRAPHIC CHARACTERISTICS OF THE RESPONDENTS (N=500)
Gender Age (years)
Male Female 20-29 30-39 40-49 50-59 60-69 ≥ 70
N 209 291 106 136 135 73 38 12
% 41.8 58.2 21.2 27.2 27.0 14.6 7.6 2.4
-----[33]-----
Percentage of Respondents 40
35
30 Health Professionals TABLE 3: KNOWLEDGE OF DISORDERS
25 Newspapers TREATED BY PHYSIOTHERAPISTS
20 Radio
15 Television Disorder Frequency Percentage
Others Blood 2 0.6
10
Bones and joints 180 52.5
5
Brain 9 2.6
0 Heart 11 3.2
Muscles 131 38.2
ls
n
o
s
s
sio
na
er
er
di
sio
ap
th
Ra
i
Cardio- 4 1.2
lev
O
sp
es
Te
ew
of
respiratory system
Pr
N
lth
Skin 3 0.9
ea
H
Source of information
Urinary system 2 0.6
TOTAL 343 100
FIGURE 1: RESPONDENTS’SOURCES OF
INFORMATION ABOUT PHYSIOTHERAPY
SERVICES
15%
Advise/Teach
TABLE 2: KNOWLEDGE OF WHERE
15% Treatment
PHYSIOTHERAPY SERVICE CAN BE
RECEIVED. 51% Screen
19% Other Help
Place Frequency Percentage
Hospitals 229 66.8
Keep-fit clubs 51 15.0
Rehabilitation centres 35 10.2
Schools 25 7.3
Others 3 0.9
Total 343 100
FIGURE 3: REASONS FOR ENCOURAGING
THE USE OF PHYSIOTHERAPY SERVICE
70
60 TABLE 4: KNOWLEDGE OF TREATMENT
50
MODALITIES USED IN PHYSIOTHERAPY
Percentage
40 Yes Modality Frequency Percentage

Ice 4 1.2
30 No
Electricity 19 5.5
20 Exercise 165 48.1
10 Heat 19 5.5
Massage 123 35.9
0 Water 5 1.5
Yes No Others 8 2.3
Encourage the use of Physiotherapy TOTAL 343 100
FIGURE 2: RESPONDENTS’ ENCOURAGEMENT OF

THE USE OF PHYSIOTHERAPY SERVICE
Knowledge of where physiotherapy service can manage disorders of the cardio-respiratory system
be received. (Table 3).
Majority of the respondents 229 (66.8%) Knowledge of treatment modalities used in
stated that physiotherapy service can be received Physiotherapy
in hospitals, 51 (15%) were of the opinion it can The participants’ knowledge of the
be received in keep-fit clubs while 35 (10.2%) different treatment modalities used by
stated that physiotherapy service can be obtained physiotherapists can be seen in Table 4. Majority
in rehabilitation centres (Table 2). (165, 48.1%) had the knowledge that
Knowledge of conditions treated by physiotherapists employ exercise as the main and
physiotherapists frequently used modality for treatment, while 123
Participants were asked about their (35.9%) knew that physiotherapists use massage
knowledge of various conditions treated by as modality for treatment. According to the
physiotherapists. Majority of the respondents respondents, cold, heat, water and others (such as
gave the response that physiotherapists treat iontophoresis, manipulation) were the least
disorders affecting bones and joints (180, 52.8%) known modalities employed by physiotherapists
while 131 (38.4%) responded that in treatment.
physiotherapists treat disorders affecting muscles. Use of respondents’ knowledge of physiotherapy.
Only 4.4% believed that physiotherapists treat or When asked whether they would advise
other people to seek the services of
-----[34]-----
physiotherapists, 216 (63.0%) responded in the working as part of the multidisciplinary health
affirmative (figure 2). As for the reasons why they team. Hence, the public associates the profession
would give such advice, 94 (43.5%) indicated that with the typical hospital environment. Therefore,
they would do this to enable other people obtain it is not surprising that many respondents in the
the physiotherapists’ advice/teaching about present study were of the opinion that
prevention of illness, while 65 (30.0%) would do physiotherapy is a branch of medicine and that
the same to enable others obtain treatment from physiotherapy service can be received in
physiotherapists (figure 3). hospitals.
A large number of the respondents knew
DISCUSSION that physiotherapists employ exercise as the main
and frequently used modality for treatment. When
This study was undertaken to assess the physiotherapists receive referrals to treat patients,
level of awareness and knowledge about they often introduce themselves, especially in the
physiotherapy services among the general public hospital wards, as people who give treatment by
in a typical African market located in Accra exercises. Statements such as “I am here to teach
metropolis, Ghana. A large number of you exercise” or “I am here to make you do some
respondents in this study had previous knowledge exercises” are used. Hence, they might have
of physiotherapy. Most of them acquired the earned the toga of exercise professionals, and
knowledge through information obtained from those who came in contact with them in this way
health professionals and the mass media. Also, might have propagated the idea to the general
most of them were of the opinion that public. The fact that exercise is associated with the
physiotherapy is a branch of medicine. Majority physiotherapy profession had been reported
of the respondents stated that physiotherapy earlier in a study by Higgs et al (2001) who noted
service can be received in hospitals and expressed the fact that exercise is considered as the
the opinion that physiotherapists treat disorders of backbone of physiotherapy practice18.
bones and joints. A large number of the In this study, most respondents
respondents knew that physiotherapists employ expressed the view that physiotherapists treat
exercise as the main and frequently used modality disorders of muscles, bones and joints. This could
for treatment. Many of them would advise other be attributed to the large number of the referrals
people to seek the services of physiotherapists in from orthopaedic units of the hospitals.
order to obtain the physiotherapists’ Invariably, the small number of physiotherapists
advice/teaching about prevention of illness, or in the country might have limited physiotherapy
receive treatment from physiotherapists. The referrals to mostly cases where the role of a
small sample size was a notable limitation of the physiotherapist is inevitable and most highly
study. Also, the small geographical area covered appreciated. In effect, the populace are only able
by the survey entails that care should be exercised to view physiotherapy services along the lines of
in comparing results of the study with those of mobilization of stiff joints and strengthening of
other studies. weak muscles. Hence, it is not surprising that the
In Europe, majority of the public are public would not be aware that physiotherapy
aware of physiotherapy services and have services could be available for conditions other
knowledge on what the profession entails, such than those of the musculoskeletal system18. A
that there is a high demand for the services of similar observation was made by Ogiwara and
physiotherapists among the people13. In Australia, Nozoe (2005) in a study among high school
physiotherapists enjoy professional autonomy and students in Japan17.
the level of awareness is high14,15,16. In Japan, Many of the participants in this study
many high school students lack appropriate who had previous knowledge about physiotherapy
information about the physiotherapy profession services would advise others to seek the services
and are therefore unaware of the vast career of physiotherapists. This would suggest that they
opportunities open to them17. In Ghana, anecdotal had a positive outlook about physiotherapy
reports suggested low level of awareness and services and would encourage other people to
knowledge of physiotherapy, and it appears that enjoy the benefits of physiotherapy service. A
the profession lacks a clear identity with the further confirmation of this positive outlook stems
public despite the great role it plays in the society. from the fact that the respondents would give such
This observation could not be fully supported by advice to enable other people obtain the
the relatively high level of awareness (68.6%) physiotherapists’ advice/teaching about
demonstrated by respondents in this study, who prevention of illness or obtain treatment from
were drawn from a market place; and were physiotherapists.
expected to show a low level of awareness.
At present, almost all physiotherapists in
Ghana practice as clinicians in the hospitals,
-----[35]-----
CONCLUSION 8. Whitfield TWA, Allison I, Laing A, Turner

PA. Perceptions of the physiotherapy
Participants in this study demonstrated a profession: A Comparative Study.
high level of awareness of physiotherapy services. Physiotherapy Theory and Practice 1996; 12:
The mass media served as the main sources of 39-48.
information that enhanced the level of awareness. 9. Hunt A, Adamson B, Harris L.
However, there is still a need for more Physiotherapists’ perceptions of the gap
enlightenment to enable the general public between education and practice.
appreciate the importance of physiotherapy Physiotherapy Theory and Practice 1998; 14:
services in Ghana. 125-138.
10. Sheppard L. Public Perception of
Physiotherapy: Implications for Marketing.
CLINICAL APPLICATION
Australian Journal of Physiotherapy 1994;
40: 265-271
Physiotherapists in Ghana need to
11. Japan Physiotherapy Association.
maintain and even build upon the level of
Physiotherapy. Available at
awareness of their profession among the general
www.soc.nii.ac.jp/jpta. Accessed on 13th
public in the country. A positive outlook about the
June 2011.
profession will go a long way to boost their
12. Lee K, Sheppard L. An investigation into
clinical practice and enhance the growth of the
medical students’ knowledge and perception
profession in the country.
of physiotherapy services. Australian Journal
of Physiotherapy 1998; 44: 239-245.
REFERENCES 13. Edwards L. Clinical reasoning in three
different fields of physiotherapy: Qualitative
1. World Confederation for Physical Therapy. case study approach. Available at
Declaration of Principles. Available at www.physiotherapy.asn.au. Accessed 5th
www.wcpt.org. Accessed 10th June 2011. June 2011.
2. Chartered Society of Physiotherapy. What is 14. Turner P. The occupational prestige of
Physiotherapy? Available at www.csp.org.uk physiotherapy: Perceptions of student
. Accessed 13th June 2011. physiotherapists in Australia. Australian
3. Moore WE. The professions; Roles and Journal of Physiotherapy 2001; 17: 191-197.
Rules. New York, Russell Sage Foundation, 15. Claude L, Dalley J. Providing a safety net:
2005. fine-tuning preparation of undergraduate
4. Higgs J, Refshauge K, Ellis E. Portrait of the physiotherapists for contemporary
physiotherapy profession: Profile of the professional practice. Learning in Health and
professions. Journal of Interprofessional Care Social Care 2002; 1: 191-201.
2001; 15: 79-89. 16. Crosbie J, Gass E, Sullivan JA, Webb G,
5. Steins AS, O’Young B, Young AM. Person- Wright T. Sustainable undergraduate
centered Rehabilitation: Interdisciplinary education and professional competency.
Intervention to Enhance Patient Enablement. Australian Journal of Physiotherapy 2002;
In: O’Young BJ, Young AM and Steins AS 48: 5-7.
(eds) Physical Medicine and Rehabilitation 17. Ogiwara S, Nozoe M. Knowledge of
Secrets (2nd edition). Philadelphia, Hanley Physiotherapy: A study of Ishikawa High
and Belfus Inc, 2001. School students. Journal of Physical Therapy
6. Rothstein JM. Autonomy and dependency. Science 2005; 17: 9-16.
Physical Therapy 2002; 82: 750-751. 18. Higgs J, Hunt A, Higgs C, Neubauer D.
7. Ghana Statistical Service. 2010 Population Physiotherapy education in the changing
and housing census. Available at international healthcare and educational
www.ghana.gov.gh/. Accessed 5th June contexts. Advances in Physiotherapy 1999; 1:
2011. 17-26
-----[36]-----
A COMPARATIVE STUDY OF ULTRASOUND AND EXERCISE VERSUS

PLACEBO ULTRASOUND AND EXERCISE IN PATIENT WITH ORAL
SUBMUCOUS FIBROSIS
Priyank Galchar1, Neela Soni2, Anjali Bhise3
1. M.PT-Rehabilitation, Govt. Physiotherapy College, Ahmedabad.
2. Sr.Lecturer, Govt. Physiotherapy College, Ahmedabad.
3. Principal, Govt. Physiotherapy College, Ahmedabad.
ABSTRACT
INTRODUCTION- Oral sub mucous fibrosis is chronic disabling disease associated with habitual betel quid chewers.
In India 2.5 million people are suffering from this disease. Characterized by limitation of oral opening resulting in
difficulty in chewing. The pathological changes are irreversible. Physiotherapy isthe third dimension to the management
apart from medication and surgery. Therapeutic ultrasound help makes fibrous tissue more pliable and helps in gradual
stretching of oral tissue.
METHODOLOGY- A comparative study was conducted on a convenient sample of 30 subjects with diagnosis of OSMF
grade-3 by E.N.T surgeon, above 18 years of age, In Civil hospital Ahmedabad. Subjects unwilling were excluded.
Procedure- 30 subjects were divided in 2 groups. Group A received treatment in form of Ultrasound and exercise, Group
B received placebo Ultrasound and exercise. MMO and VAS for pain were used for outcome measure.
RESULTS-Results revealed that both group had significant improvement in MMO and VAS. Ultrasound with Exercise
were highly significant (p<0.0001) in Group A.
KEYWORDS-Ultrasound, mouth opening, pain, oral sensitivity.
INTRODUCTION areca nut, promotes salivation, stains saliva red,

and is a stimulant.
Oral sub mucous fibrosis has now In most patients with oral sub mucous
become an Indian epidemic with an estimated 2.5 fibrosis, areca nut was chewed alone more
million people being affected with this frequently than it was chewed in combination with
disease1.The rate varies from 0.2-2.3% in males pan2 or had a higher areca nut content4.
and 1.2-4.57% in females in Indian communities2. The term oral sub mucosal fibrosis
Oral sub mucous fibrosis also has a significant derives from oral (meaning mouth), sub mucosal
mortality rate because it can transform into Oral (meaning below the mucosa of the mouth), and
cancer, particularly squamous cell carcinoma, at a fibrosis (meaning hardening and scarring)2.
rate of 7.6%1. It is a premalignant condition with Chewable agents, primarily betel nuts (Areca
15 % of all cases converted to malignancy2. catechu), contain substances that irritate the oral
Oral sub mucous fibrosis is a chronic mucosa, making it lose its elasticity. Nutritional
debilitating disease of the oral cavity deficiencies, ingestion of chilies, and
characterized by inflammation and progressive immunologic processes may also have a role in
fibrosis of the sub mucosal tissues (lamina propria the development of oral sub mucous fibrosis1.
and deeper connective tissues). Oral sub mucous The treatment of patients with oral sub
fibrosis results in marked rigidity and an eventual mucous fibrosis depends on the degree of clinical
inability to open the mouth2. The buccal mucosa involvement. If the disease is detected at a very
is the most commonly involved site, but any part early stage, cessation of the habit is sufficient.
of the oral cavity can be involved, even the Most patients with oral sub mucous fibrosis
pharynx3. present with moderate-to-severe disease.
The condition is well recognized for its Moderate-to-severe oral sub mucous fibrosis is
malignant potential and is particularly associated irreversible. Medical treatment is symptomatic
with areca nut chewing, the main component of and predominantly aimed at improving mouth
betel quid. Betel quid chewing is a habit practiced movements.2 Treatment strategies include
predominately in Southeast Asia and India that steroids, placental extracts5,6, hyaluronidase7,
dates back for thousands of years. It is similar to IFN-gamma8, lycopene and pentoxifylline.
tobacco chewing in westernized societies. The Surgical treatment is indicated in
mixture of this quid, or chew, is a combination of patients with severe trismus and/or biopsy results
the areca nut and betel leaf, tobacco, slaked lime, revealing dysplastic or neoplastic changes.
and catechu1. Lime acts to keep the active Surgical modalities that have been used include
ingredient in its freebase or alkaline form, simple excision of the fibrous bands, split-
enabling it to enter the bloodstream via sublingual thickness skin grafting following bilateral
absorption. Arecoline, an alkaloid found in the temporalis myotomy or coronoidectomy,
-----[37]-----
nasolabial flaps and lingual pedicle flaps9 and use Exercise includes:
of a KTP-532 laser10. STRETCHING EXERCISES11,14:
The physiotherapy is third dimension of (1)With the use of mouth opening
treatment in oral sub mucous fibrosis, which device:
include  Patient’s position : supine
• Ultrasonic treatment: ultrasonic waves  Mouth opening device was used .Held for 20
produce tissue heating at a deeper level seconds.4-5 repetitions per session.
than moist heat; this increase in local (2) Active and passive stretching:
tissue temperature leads to increase in
blood flow and removal of metabolic by  The patient is instructed to actively open the
products responsible for pain and may mouth as wide as possible. The opening
help decrease adhesions by disrupting position should be held for 5 seconds
collagen cross-linkage. followed by relaxation in the rest position for
• Stretching exercises: Physical therapy 5 seconds.
using muscle-stretching exercises for the  In passive stretch patient is instructed to
mouth may be helpful in preventing actively open the mouth. Then finger pressure
further limitation of mouth movements. is applied by therapist to the maxillary and
This is often combined with medical and mandibular dentitions with use of thumb and
surgical therapy11. index finger.
The purpose of study was to compare the  Stretching exercises is performed by using ice
effect of ultrasound over placebo ultrasound in cream sticks for 5-10 minutes 3-4 repetitions
patient with oral sub mucous fibrosis. 4 times in a day. Stretching exercises is
performed at home using ice cream sticks for
5-10 minutes 3-4 repetitions 4 times in a day.
METHODOLOGY
ISOMETRIC EXERCISES11,15:
A comparative study was performed on  The resistance is applied by therapist or
convenient sample of 30 subjects at Govt. patient using hand or fingers placed on
Physiotherapy College, civil hospital, mandible.
Ahmedabad. The subjects were selected by simple  Resistance applied to the all movements.
random sampling. Inclusion criteria were (1) Hold for 6-10 seconds for 10 times for each
Patients who are willing to participate in the study movement. Patient should be on home
(2) Age: 20-40 years. (3) Both sex (4) Patients programmed.
diagnosed as oral sub mucous fibrosis by qualified PLACEBO ULTRASOUND:
ENT specialist (stage 3). Stage 3 includes Burning
 Placebo Ultrasound is given in switch off
sensation and dryness of mouth, Irritation with
Mode of machine.
spicy food, Vertical fibrotic bands on buccal
mucosa and retromolar areas. Subjects excluded  It is only given for Placebo Effect.
were (1) Malignancy (2) Injections of Steroids (3) There were two outcome measures were
Metal Implants (4) Previous trauma/fracture used.
around TMJ. (1) Maximum Mouth Opening: MMO is
Prior to the Commencement of the study, a reliable, objective measure of mouth opening.
consent was taken from all subjects. 30 were Maximal mouth opening was measured in mm
subjects divided in to 2 groups, Group A having using ruler. Measurement was taken with subject
15 subjects and Group B having 15 subjects. in sitting or supine position. Measurement of
Group A, 15 subjects were treated with maximal voluntary mandibular opening can be
Ultrasound and Exercise. Group B, 15 subjects obtained by measuring between the maxillary and
were treated with Placebo Ultrasound and mandibular incisal edges with a ruler scaled in
Exercise. Study duration was 4 weeks, every millimeters.
subjects were treated 6 days in week one session (2) VAS scale for pain: Visual analogue
daily. The subjects also asked the exercise scale is used to represent measurement quantities,
programmes at home. in terms of a straight line placed horizontally on
ULTRASOUND11,12,13: Treatment was paper. The subject is asked to place a mark on that
given with following dosage: line, which is 10 cm in length. The left end of line
represents no pain and right end represents severe
 Mode: Pulsed
pain.
 Frequency: 1 MHz
Clinical examination was done with
 Intensity: 0.5 Watt/ cm2 exactly the same protocols after the treatment
 Duration: 5 minutes/ session period i.e. at the end of 4 weeks to measure VAS
 Use of mouth opening device to provide for pain and MMO in OSMF patients in both
stretch during application of US. groups.
-----[38]-----
DATA ANALYSIS mouth opening within Group A and Group B. For

group A, t = 20.92 with the two-tailed p value is
Mean of the pre and post treatment 0.0001, considered significant. For group B, t =
MMO and VAS was taken and then standard 7.48 with the two tailed p value is<0.0001,
deviation was calculated. Wilcoxon test was considered significant.
applied for comparison of pretreatment and post Comparison of Mean Maximal Mouth opening in
treatment pain scores as on VAS within Group A Both Groups
and Group B. Mann-Whitney test was applied for
27.55 27.25
comparison of post treatment VAS score between 30
23.25
20.77
Group A and Group B. Paired t test was applied
20
for comparison of pretreatment and post treatment Group A
maximal mouth opening within Group A and 10 Group B
Group B. Unpaired t test was applied for
0
comparison of post treatment maximal mouth Pre MMO Post MMO
opening between Group A and Group B.
FIGURE 3: COMPARISON OF MEAN
RESULTS MAXIMAL MOUTH OPENING IN BOTH
GROUPS
Out of 30 subjects 13 were females and
17 were males. Wilcoxon test was applied for Unpaired t test was applied for
comparison of pretreatment and post treatment comparison of post treatment maximal mouth
pain scores as on VAS within Group A and Group opening between Group A and Group B. And
B. For group A, W = 45.00 and the two-tailed p value of t = 4.56 with two-tailed p value is 0.0004,
value is 0.008, considered significant. For group considered significant.
B, W = 23.00 and the two-tailed p value is 0.01, Difference between Group A, B post MMO
considered significant. 8
Pre treatment and post treatment pain scores as 6.77
on VAS within Group A and Group B. 6
6 5.22
4
4.25 4
4 3.12
2.66 Group A 2
Group B
2 0
GROUP A GROUP B
0
Pre VAS Post VAS FIGURE 4: PRE AND POST MAXIMAL MOUTH
OPENIND DIFFERENCE BETWEEN GROUP A
AND B
FIGURE 1: PRETREATMENT AND POST
TREATMENT PAIN SCORES AS ON VAS
WITHIN GROUP A AND GROUP B. DISCUSSION
Mann-Whitney test was applied for The results of present study showed that
comparison of post treatment VAS score between the reduction in pain and improvement in maximal
Group A and Group B and value of U=7.5, the mouth opening was appreciably significant in
two-tailed p value is 0.0005, considered both the groups. The results indicated that
significant. Ultrasound when given along with Exercise
Difference between Groups A,B
resulted in significantly better subjective and
Post VAS objective outcomes than Placebo ultrasound and
2.55
Exercise in patients with Oral sub mucous
3
Fibrosis.
2 The electrotherapeutic modality given
1.12 was ultrasound. Pain relief by ultrasound occurs
1
by directly influencing the transmission of painful
0 impulses by eliciting changes within the nerve
GROUP A GROUP B fibers and elevating pain threshold. Whereas
indirect pain reduction occurs as a result of
FIGURE 2: VAS DIFFERENCE BETWEEN increased blood flow and increased capillary
GROUPS A AND B
permeability to the affected area. This effect of
pain reduction was reflected by reduction on the
Paired t test was applied for comparison score of VAS16.
of pretreatment and post treatment maximal
-----[39]-----
According to Byl, NN (1992) opening in the Group A was almost twice the
cycloaminoglycan and hydroxyproline which magnitude of the improvement observed in the
were the essential components for collagen Group B. On assessing few patients who came for
production were increased following low dose follow up, it was found that subjects in the Group
pulsed ultrasound. Cavitation and acoustic A treated with Ultrasound appeared less likely to
streaming facilitate collagen synthesis. This be taking medications and were more satisfied
increased rate of `collagen synthesis in disc results with the overall outcome of their rehabilitative
in healing and increased tensile strength of disc16. treatment at 4 weeks compared with subjects in
Binder A et al (1985) studied the the Group B with Placebo Ultrasound.
effectiveness of ultrasound in TMD patients. He
compared ultrasound with placebo. He found CLINICAL APPLICATION
improvement in pain score and mouth opening.
Pulse ultrasound was not found to be effective as The programme of Ultrasound with
a sole treatment in treating chronic Exercise is safe & effective if an early & regular
temporomandibular pain. Similar procedure used basis carried out in Oral Sub Mucous Fibrosis
in the study by Haker and Lundenberg (1991) in .This is useful in improving the pain and mouth
which they report no beneficial effect for pulsed opening.
ultrasound over placebo ultrasound18.
The use of ultrasound on this condition
was based on the effect of ultrasound which is
FUNDING
both thermal and non-thermal, producing an
increase in extensibility of soft tissue (Richard A The above study is not funded by any
Ekstrom et al, 2002) and stimulation of collagen institute or person and is completely based upon
synthesis through ultrasound induced cavitation authors at their own interest.
(Webster et al, 1980).
Exercise therapy has long been used in CONFLICTS OF INTEREST
the treatment of TMDs. Therapeutic exercise
interventions are prescribed to address specific There was no personal conflicts of
TMJ impairments and to improve the function of interest.
the TMJ and craniomandibular system. Most
exercise programs are designed to improve REFERENCES
muscular coordination, relax tense muscles,
increase range of motion, and increase muscular 1. Cox SC, Walker DM. OSMF .A review. Aust
strength (force-generating capacity).The most Dent J. Oct 1996;41(5):294-9
useful techniques for re-education and 2. AZIZ SR. OSMF. An usual disease .J N J Dent
rehabilitation of the masticatory muscles have Assoc. Spring 1997;68(2):17-9.
been reported as manual therapy, muscle 3. Paissat DK. OSMF. Int J Oral Surg. Oct 1981
stretching, and strengthening exercises. Passive ;10 (5) : 307-12.
and active stretching of muscles or range-of 4. Tilkaratne WM, Klinikowski MF , Saku T ,
motion exercise are performed to increase oral Peters TJ , Warnakulasuriya S . OSMF: review
opening and decrease pain17. on aetiology and pathogenesis. Oral Oncol .
The progressive fibrosis, which occurs in Jul 2006; 42(6) : 561-8.
the patients, diagnosed with Oral sub mucosal 5. Sur TK, Biswas TK, Mukhrjee B. Anti-
fibrosis, seem to improve with stretching exercise inflammatory and anti-platelet aggregation
as stretching causes better alignment of fibrotic activity of human placental extract. Acta
tissue. This method was considered in the study Pharmacol Sin. Feb 2003;24(2):187-92.
conducted at the school of dentistry, Taiwan, by 6. Anil S, Beena VT. Oral sub mucous fibrosis in
Lis DR and associated (1995). 12 –year old girl: case report.Pediatr Dent.
Mar-Apr 1993; 15(2):120-2.
LIMITATIONS 7. Kakar PK, Puri RK, Venkatachalam VP. Oral
sub mucous fibrosis- treatment with hylase. J
• The sample size was small. Laryngol Otol. Jan 1985; 99 (1): 57-9.
• Home programme taught to the patients was 8. Haque MF, Meghji S, Nazir R, Harris M.
not supervised. Interferon gamma may reverse oral sub
• Body mass index was not noted. mucous fibrosis. J Oral Pathol Med. Jan 2001;
30 (1): 12-21.
CONCLUSION 9. Hosein M. Oral cancer in Pakistan. The
problem and can we reduce it?. In: oral
The result of this study suggest that the Oncology. Kluwer Academic: 1994.
average improvement in pain and maximal mouth
-----[40]-----
10.Nayak DR, Mahesh SG, Aggrawal D, 15.C.Kisner, L.A.Colby, 5th Edition 2007:168-
Pavitharan P, Pujaray K, Pillai S. Role of KTP- 170:Jaypee Publication, Resistance Exercise
532 laser in management of oral sub mucous for Impaired Muscle Performance.
fibrosis. J Laryngol Otol. Oct 2008; 1-4. 16.D.W. OH et al; The effect of physiotherapy on
11.Arora PK, Despande M. Effect of ultrasound Post temporomandibular joint surgery
and exercise in case of OSMF Indian Journal patients; J Oral Rehabil.;2002;
of Physiotherapy and Occupational therapy May;29(5):441-6.
2010:4 (3);45-47. 17.Friedman et al; Post surgical
12.David Rubin. Ultrasonic Therapy. temporomandibular joint hypomobility.
Physiological effect and clinical application Rehabilitation technique; Oral Surg. Oral Med
1958;Nov:89 (5):349-351. Oral pathology ; 1993 ; Jan ; 75 (1);24-8.
13.Taneja L, Nagpal A, Vohra P. OSMF An Oral 18.Haker;TMD: Diagnosis, treatment &
Physician Approach. Journal of Innovative evalution; critical reviews in physical &
Dentistry 2011;Dec:1(3). rehabilitation medicine, 5, 129-154,1993.
14.C.Kisner, L.A.Colby, 5thEdition 2007: 77-79:
Jaypee Publication, Stretching for Impaired
Mobility.
-----[41]-----
TO ASSESS AND COMPARE THE SHORT TERM EFFECT OF

ATLANTO-OCCIPITAL JOINT MANIPULATION AND SUBOCCIPITAL
MUSCLE INHIBITION TECHNIQUE ON ACTIVE MOUTH OPENING
RANGE
Khyati Harish Sanghvi1, Ganesh Subbiah2, Amrit Kaur3
1.Physiotherapist, B.P.T, Department of Physiotherapy, Somaiya Diagnostic Center and Polyclinic.
Mumbai
2.Physiotherapist, M.P.T, Associate Professor, Department of Musculoskeletal Sciences, N.D.V.P.M
College of Physiotherapy. Nashik
3.Physiotherapist, M.P.T, Assistant Professor, Department of Community Based Rehabilitation, N.D.V.P.M
College of Physiotherapy Nashik
ABSTRACT
INTRODUCTION: The temporomandibular joint is directly related to the cervical and scapular region. Disturbances
in the temporomandibular joint can affect the positioning of the skull over the cervical region and can determine the
postural imbalance through a common neuromuscular system. The purpose of this study was to assess and compare short
term effect of atlanto-occipital joint manipulation and sub-occipital muscle inhibition technique on active mouth opening
range.
MATERIAL AND METHODS: 30 subjects were selected to participate in this study. TMJ opening range was measured.
The subjects were divided randomly in two groups. Group A received Atlanto-occipital joint manipulation. Group B
received Sub-occipital muscle inhibition technique. The treatment was given daily for 1 week. The TMJ opening range
was measured after a week (6th day). Paired and unpaired t-test was used for data analysis.
RESULT: Both atlanto-occipital joint manipulation and sub-occipital muscle inhibition technique was effective in
improving active mouth opening range. But atlanto-occipital joint manipulation was more effective in improving active
mouth opening range then sub-occipital muscle inhibition technique.
CONCLUSION: The result of this study concluded that atlanto-occipital joint manipulation was more effective in
improving active mouth opening range then sub-occipital muscle inhibition technique.
KEYWORDS: Temporomandibular Joint; Active Mouth Opening Range.
INTRODUCTION One of the signs often associated with

TMD is a reduction in mouth-opening capacity10.
Temporomandibular disorders (TMD) The reference range of mouth opening reported in
are a group of disorders affecting the masticatory the literature ranges from 41 to 50.7 mm11,12.
muscles and/or temporomandibular joint (TMJ)1,2. Mouth-opening measurements are generally
TMD affects more than 25% of the general greater in men, in tall, and in young individuals.
population3. It is estimated that between 85 to 95 A mouth-opening measurement less than 40 mm
percent of population will exhibit one or more of is considered restricted12. During normal mouth
symptoms of TMD in their lifetime with 5 to 6 % opening, extension occurs at the cervico-cranial
of the population reporting clinically significant junction; and restriction in the upper cervical
TMD related jaw pain4,5. TMD can be classified spine may decrease a patient's mouth-opening
as joint or muscular disorder or both. Joint capacity13. De Laat et al (1998) found that
disorders include internal derangement, segmental limitations in the upper cervical spine
dislocation, inflammatory conditions, arthritis, (C0-C3) were significantly more present in
ankylosis and deviation in form. Myofacial pain, patients with TMD than controls14. Various
myositis, spasm, and muscle contracture comprise studies have also shown the evidences of a greater
the muscular group6. TMD have a wide range number of cervical spine signs and symptoms in
symptoms including restricted range of mouth temporomandibular dysfunction patients and
opening, locking, clicking, headaches and vice-versa.
commonly joint and muscle pain. It is also Any alteration in TMJ range leads to
commonly associated with other symptoms Masticatory muscle imbalance and subsequently
affecting the head and neck regions such as TMD, which in turn affects the cervical
headache, ear-related symptoms and cervical musculature and leads to postural dysfunction.
spine disorders7,8. Patients with chronic TMD Hence it’s better to improve the TMJ range before
frequently report symptoms of depression, poor the patient develops TMD and subsequent CSD.
sleep quality, and low energy9. Usually in subjects with restricted mouth opening,
there is restriction of upper cervical extension;
-----[42]-----
hence cervical manual therapy can be used to Group A received Atlanto-occipital joint
increase TMJ opening range. manipulation. Group B received Sub-occipital
The current study is being done to muscle inhibition technique.
evaluate the effectiveness of atlanto-occipital Atlanto-occipital joint manipulation Technique:
joint manipulation and sub-occipital (upper
The subject is taken in supine lying. The
cervical) muscle inhibition technique on active
head is rotated to one side (restricted side of
TMJ opening. The finding of this study can be
cervical rotation). With the middle and ring finger
used to modify treatment protocol in patients with
of inferior hand, the therapist contacts the mastoid
TMD.
process. With the palm of the cranial hand, the
therapist contacts the subject’s jaw line and cheek.
METHODS Both forearms of the therapist are in plane parallel
with the subject. A slight traction in cranial
SAMPLE SIZE direction is introduced with both the hands. When
Total Sample size – 30 joint tension is perceived by the therapist, a thrust
Group A – 15 subjects receiving Atlanto- is performed in the direction of traction with a
occipital Manipulation. gentle rotatory force. If no popping sound is heard
Group B – 15 subjects receiving Sub- on the 1st manipulative attempt, the therapist
occipital muscle inhibition Technique. repositions again and performs a 2nd
manipulation. A maximum of 2 thrust attempts is
TYPE OF STUDY
performed in 1 session on each subject.
Comparative Study
Sub-occipital Muscle Inhibition Technique:
STUDY SETTING The subject is taken in supine; therapist
N.D.M.V.P College and Hostel. is seated at his head with elbow resting on the
surface of table. The therapist places both the
INCLUSION CRITERIA hands behind the head of subject, with the palms
facing upwards, the fingers flexed, and the finger
 People with restricted maximum active pads positioned on the posterior arch of atlas, to
mouth opening; i.e. mouth opening ROM is allow the occiput to rest in the palm of hands. A
less than 40mm. force is applied with the finger pads over the atlas
 Aging from 18 to 30 years. in a direction of ceiling with slight traction in
 Both the genders. cranial direction for 2 minutes.
EXCLUSION CRITERIA The treatment intervention was given
daily for 1 week. The TMJ opening range was
 Previous history of jaw and/or neck measured with scale10 after a week (6th
injury/surgery; day).Paired and unpaired t-test was used for data
 previous or current TMJ or cervical pain analysis.
lasting for more than 3 weeks;
 Any contraindications for cervical
manipulation including acute fracture,
RESULTS
vascular insufficiency, or cervical spine
30 individuals with restricted mouth
instability.
opening range were selected to participate in the
 General joint disorder involving head and
study. The participants were divided into 2
neck including rheumatoid arthritis.
groups;
OUTCOME MEASURE Group A: 15 subjects receiving Atlanto-
Active ROM of TMJ Opening (inter- occipital joint Manipulations
incisor range) using Ruler (Walker et al 2000). Group B: 15 subjects receiving Sub-
occipital muscle inhibition technique.
MATERIALS REQUIRED Descriptive data is given in table 1.
Plinth/couch, Scale/Ruler, Pen, Paper
Paired t-test
It was used to compare the pre and post
PROCEDURE treatment active mouth opening range within the
30 subjects were selected on the basis of group.
inclusion criteria. Subjects were informed about Group A:
the study and written consent was taken from
them. Subjective data like name, age, sex, past t= 12.2
history were collected. TMJ opening range was Degrees of freedom = 14
measured with ruler/scale10. The subjects were The probability of this result is 0.000.
divided randomly in two groups, 15 in each group. As t=12.2 and p<0.05, the result is
statistically significant, i.e.; Atlanto-occipital
-----[43]-----
joint manipulations have significant effect in manipulation or soft tissue technique targeted to
improving mouth opening ROM. sub-occipital muscles led to immediate increase in
Group B pressure pain threshold over latent trigger points
and an increase in maximum active mouth
t= 6.81
opening15.
Degrees of freedom = 14
The relationship between the
The probability of this result is 0.000.
temporomandibular joint and cervical spine is
As t=6.81 and p<0.05, the result is
prove already in many previous study.
statistically significant, i.e.; Sub-occipital muscle
Physiological dynamic equilibrium of both
inhibition technique have significant effect in
regions constitutes the ideal case. Hence changes
improving mouth opening ROM.
in one region can lead to changes in other region
too. The ideal posture of head places the center of
TABLE 1: DESCRIPTIVE DATA OF BOTH
GROUPS
gravity slightly anterior to the cervical spine. For
this reason, when sitting or standing the head falls
Group A Group B anteriorly if the muscles of the head and neck are
Atlanto-occipital Joint Sub-occipital Muscle totally relaxed. When the mouth is opened, the
Manipulations Inhibition Technique
sub-occipital muscles counteracts the tilting
15 00 15
N forward of the head; conversely, when the head is
Mean SD Mean SD bent backwards, the masticatory muscles are
Age 21.6 3.57504579 22.33 3.457222 activated to prevent the mouth from opening
Pretreatment 31.5mm 4.1380925 31.33mm 4.980916 automatically.
ROM A forward head posture frequently
Post treatment 41.73mm 5.18881581 36.67mm 3.086067 involves extension of the occiput and upper
ROM (day 6)
cervical spine, leading to compensatory flattening
Unpaired t-test of lower cervical spine and upper thoracic spine to
It was used to compare post treatment achieve a level head position16.With the occiput
mouth opening ROM between the group, i.e.; extended on atlas (c1) the sub-occipital muscles
Group A and Group B. adapt and shorten. Increased tension from
Group A: Number of items= 15 shortening of sub-occipital muscle may lead to
Mean = 10.2 headaches that originate in sub-occipital area,
Standard Deviation = 3.23 limitation in active range of motion, and
Group B: Number of items= 15 temporomandibular joint dysfunction16.
Mean = 5.33 Thus, it is proposed that cervical posture
Standard Deviation = 3.04. should be normalized by sub-occipital muscle
The result was, t= 4.25 inhibition technique (to normalize sub-occipital
Standard deviation= 3.14 muscle length) or atlanto-occipital joint
Degrees of freedom = 28 manipulation (to normalize upper cervical spine
The probability of this result is 0.000 active range of motion) to successfully either
As t=4.25 and p<0.05, the result is prevent if not present or treat dysfunction of
statistically significant, i.e.; Atlanto-occipital temporomandibular joint.
joint manipulations has more effect on mouth
opening ROM then Sub-occipital muscle LIMITATIONS
inhibition technique.
 Small sample size (15 in each group).
DISCUSSION  There was no follow up study done.
The result of this study demonstrated that SUGGESTIONS

both Atlanto-occipital joint manipulations and
sub-occipital muscle inhibition technique have  More studies with long term follow-up
significant effect on mouth opening ROM. should be carried out.
Though on comparison it was found that atlanto-  Exercise protocol should be added to the
occipital joint manipulation have better effect on treatment for better results.
mouth opening ROM then sub-occipital muscle
inhibition technique.
James et al (2007) concluded that
CONCLUSION
Manual therapy to the cervical spine did not
significantly improve mouth opening in this The result of this study concluded that
asymptomatic population3. atlanto-occipital joint manipulation was more
Natalia et al (2010) concluded that the effective in improving active mouth opening
application of an atlanto-occipital thrust
-----[44]-----
range then sub-occipital muscle inhibition 6. Yap A and Ho V (1999):

technique. Temporomandibular disorders – An
Overview. Singapore Medical Journal 40(3):
KEY POINTS 179-182.
7. Gremillion H (2000): The prevalence and
• The mandible and the base of skull presents etiology of temporomandibular disorders and
the muscular and ligamentous connections orofacial pain. Texas Dental Journal 117:30-
with the cervical region, forming a functional 39.
system known as cranio-cervico-mandibular 8. Benoit P (1994): History and physical
system. examination for TMD. In Kraus SL, Ed.
• Atlanto-occipital joint manipulations have Temporomandibular Disorders. 2nd Ed. New
significant effect in improving TMJ opening York, NY: Churchill Livingstone; 71-98.
ROM. 9. Morris S, Benjamin S, Gray R and Bennet D
• Sub-occipital muscle inhibition techniques (1997): Physical, psychiatric and social
have good effect in improving TMJ opening characteristics of the TMD pain dysfunction
ROM. syndrome: the relationship of mental
• Atlanto-occipital joint manipulation is more disorders to presentation. British Dental
effective then Sub-occipital muscle inhibition Journal 182:25-26.
technique in improving active mouth 10. Walker N, Bohannon RW and Cameron D
opening. (2000): Discriminate validity of
temporomandibular joint range of motion
measurements obtained with a ruler. Journal
ACKNOWLEDGEMENT of Orthopaedic and Sports Physical Therapy
30(8):484-492.
The authors would like to acknowledge 11. Cox SC and Walker DM (1997): Establishing
Dr. Mahesh Mitra (Principal, NDMVP College of a normal range for mouth opening: its use in
Physiotherapy) for his contribution. screening for submucous fibrosis. British
Journal of Oral and Maxillofacial Surgery
REFRENCES 35:40-42.
12. Feteih RM (2006): Signs and symptoms of
1. Nunez SC, Garcez AS, Suzuki SS and temporomandibular disorders and oral
Ribeiro MS (2006): Management of mouth parafunctions in urban Saudi Arabian
opening in patients with temporomandibular adolescents: a research report. Head Face
disorders through low-level laser therapy and Medicine 2:25.
transcutaneous electrical neural stimulation. 13. Eriksson P, Haggman-Henrikson B, Nordh E
Photomed Laser Surg 24:45-9. and Zafar H (2000): Coordinated mandibular
2. Olivo SA, Bravo J, Magee DJ, Thie NMR, and head-neck movements during rhythmic
Major PW and Flores- Mir C (2006): The jaw activities in man. Journal of Dental
association between head and cervical Research 79:1378-1384.
posture and temporomandibular disorders: a 14. De Laat A, Meuleman H, Stevens A and
systematic review. Journal of Orofacial Pain Verbeke G (1998): Correlation between
20:9-23. cervical spine and temporomandibular
3. James G, Jason F, Adam M, Martha N and disorders. Clinical Oral Investigations 2:54-
Clayton S (2007): The effect of cervical spine 57.
manual therapy on normal mouth opening in 15. Natalia O, Jose R, Francisco M, Francisco A
asymptomatic subjects. Journal of and Cesar F (2010): The Immediate Effects
Chiropractic Medicine 6, 141–145. of Atlanto-occipital Joint Manipulation and
4. Saghafi D and Curl D (1995): Chiropractic Suboccipital Muscle Inhibition Technique on
Manipulation of anteriorly displaced Active Mouth Opening and Pressure Pain
temporomandibular disc with adhesion. Sensitivity Over Latent Myofascial Trigger
Journal of Manipulative and Physiological Points in the Masticatory Muscles Journal of
Therapeutics 18:98-104. Orthopaedic and Sports Physical Therapy 40,
5. Goulet JP, Lavigne GJ and Lund JP (1995): No.5, 310-317.
Jaw pain prevalence among French-speaking 16. Pamela K and Cynthia C (2006): Joint
Canadians in Quebec and related symptoms Structure & Function, a Comprehensive
of temporomandibular disorders, Journal of Analysis, 4th ed. Jaypee Brothers, 223-224.
Dental Research. Nov; 74(11):1738-1744.
-----[45]-----
AN ANALYTICAL STUDY TO FIND OUT THE EFFECTS OF FOUR

ASANAS ON DECREASING BLOOD PRESSURE AND TO COMPARE
IMMEDIATE EFFECTS ON BLOOD PRESSURE OF FOUR DIFFERENT
SEQUENCES OF COMMON ASANAS USED IN TREATMENT OF
HYPERTENSION
Gagnika kapoor1
1Lecturer, Swami Narayan Physiotherapy College, Jamnagar, Gujarat.
ABSTRACT
OBJECTIVE: To investigate the immediate effects of yoga asanas i.e. urdhvartadasana, tirayaktadasana,
katichakrasana, tiryakbhujangasana, on B.P in hypertensive patients and also to compare which sequence of yoga asanas
will be better in reducing B.P. in hypertensive patients. Random sampling method including age group of (30 – 60) years
and subject with essential hypertension. The sequence of asanas which are being applied on subjects divided in four
groups on random basis:-
Group (a) urdhvartadasana  tirayaktadasana  katichakrasana  tiryakbhujangasana.
Group (b) tirayaktadasana  katichakrasana  tiryakbhujangasana  urdhvartadasana.
Group (c) katichakrasana  tiryakbhujangasana  urdhvartadasana  Tirayaktadasana.
Group (d) tiryakbhujangasana  urdhvartadasana  Tirayaktadasana  katichakrasana.
RESULT AND CONCLUSION: The data analysis reveal that there was a significant reduction in the systolic B.P with
application of all the four groups immediately after performing yoga asanas, but analysis of variance reveals that the
mean reduction in systolic B.P between all the four groups failed to achieve significance. To conclude that patients within
the age group of 30-60 years were observed and analysis clarified that all the groups displayed significant reduction in
B.P, irrespective of sequences adopted but group (c) proved to be the most beneficial effect among all the four groups
whereas all the other groups failed to achieve within the group significance.
INTRODUCTION However, most diuretics also cause excretion of

potassium in the urine, and individuals on
Blood pressure is the force with which diuretics should monitor their potassium intake4.
blood pushes against the artery walls as it travels Drugs used to control hypertension include beta
through the body. It is measured by 2 numbers- blokers (e.g., atenolol {tenorim}) which acts to
systolic pressure & diastolic pressure. Systolic slow heart rate and cause some vasodilation.
pressure measures cardiac output and refers to the Drugs that contain calcium channel blockers (e.g.
pressure in the arterial system at its highest. amlopidine [norvasc] or angiotensin converting
Diastolic pressure measures peripheral resistance enzyme inhibitors also cause vasodilation5.
refers to arterial pressure at its lowest1. Normal Yoga improves physical, mental, psychic
blood pressure for an adult is 120/70(on average), and spiritual health. It makes the physiological
but normal individual varies with the height, reflexes, reaction & responses more alert,
weight, fitness level, age and health of a person. sensitive and subtle6. It exercises and energies the
Nearly 40% of all deaths among those 65 and various system of body14. The asanas are so
older can be attributed to heart problems. By age designed that their effects may reach to the very
80, men are 9 times more likely to die of chronic ends of the peripheral nerve tips to the vasa
heart failure then they were at age of 50. Among nervorum and vasa vasorum and the nutrient
women, this risk increases 11 fold over the same arteries which pierce and ply through bones to
time period2. supply the marrow and even to each individual
Hypertension or high blood pressure can cells7. Yoga awakens man to the realities of
be defined as a reading of 140/90 on three existence, infuses hope and courage, rekindles
consecutive measurements at atleast six hours zest and zeal8.
apart. Consistently high BP causes heart to work
harder than it should and can damage the coronary AIM & PURPOSE OF STUDY:
arteries, the brain, the kidneys & the eyes.
Hypertension is a major cause of stroke3. •To find the immediate effects of yoga
Hypertension is commonly treated with asanas i.e. urdhvartadasana, tirayaktadasana,
medication and a combination of two or more katichakrasana, tiryakbhujangasana on blood
drugs is common. Patients are usually given a pressure in hypertensive patients with in the age
diuretics to help them excrete excess fluids. group of 30-60 years.
-----[46]-----
•To compare which sequences of yoga Research setting: the research was
asanas will be better in reducing blood pressure in conducted, outpatient department of SBSPGI,
hypertensive patients with in age group of 30-60 Dehradun, Uttrakhand.
years. Sampling method: random sampling
method.
METHODOLOGY
Inclusion criteria:
Population: All the people residing in •Age 30-60 yrs.
Balawala, Dehradun, Uttrakhand. •Subjects with essential hypertension.
Research design: it is an experimental
study to find out the effects of yoga asanas i.e., Exclusion criteria:
urdhvartadasana, tirayaktadasana, katichakrasana, •Any complaint of dizziness or vertigo.
tiryakbhujangasana on blood pressure in •Patient on anti-hypertensive drugs.
hypertension patients. •Neuro- musculoskeletal disorder.
Sample size: 60 subjects between the
Group allocation:
age group of 30-60 years.
The sequence of asanas which are being
applied on subjects divided in four groups on
random basis:-
Group (a) urdhvartadasana  tirayaktadasana  katichakrasana  tiryakbhujangasana.
Group (b) tirayaktadasana  katichakrasana  tiryakbhujangasana  urdhvartadasana.
Group (c) katichakrasana  tiryakbhujangasana  urdhvartadasana Tirayaktadasana.
Group (d) tiryakbhujangasana  urdhvartadasana  Tirayaktadasana  katichakrasana.
TECHNIQUE & PROCEDURE:
Subject is in sitting supported position
with arm & hand also supported.
Sphygmomanometer and stethoscope was used
for measuring blood pressure. Firstly measure
blood pressure before the asanas & then after the
asanas one by one after every 4 asanas.
Urdhvartadasana: instruct the patient to
stand straight. Clasp the hand and palm facing
upward take it up straight above the head
gradually raise both the heel upward and maintain
it. Repeat this for 10 times with deep breathing.
Tirayaktadasana: instruct the patient to FIGURE 1: URDHVARTADASAN
stand with both hands together and finger clasped
on the head with palm facing upward. Feet to be
apart with the distance of 1 feet. While on inhaling
bend on the right side with arms in the stretched
position. Ask not to flex the elbow. While
exhaling get back to starting position and repeat
the procedure on the left side & repeat this for 10
times.
Katichakrasana: instruct the patient to
stand on wide base of support with right hand on
left shoulder and dorsal surface of left hand on
right buttock. Now ask the patient to rotate
towards the left while inhaling and come back to
normal position while exhaling & repeat this for FIGURE 2: TIRYAKBHUJANGASANA
10 times.
Tiryakbhujangasana: patient position,
prone lying on hands. Instruct the patient to keep
Feet apart with the distance of 1 feet and ankle
planter flexed. While inhaling lift the trunk up and
try to see the same side of heel. Then ask to get
back to normal position and repeat it again on the
other side. Repeat this for 10 times.
-----[47]-----
TABLE 3: TABLE SHOWING THE

IMPROVEMENT BETWEEN THE PRE-POST
READINGS AFTER PERFORMING ASANAS.
Pre readings before Post readings after Significance
performing asanas performing asanas
156 140.54 S
DISCUSSION
60 subjects between the age group of 30-
60 years were randomly divided into 4 groups to
see effectiveness of 4 yoga asanas in reducing
Systolic Blood Pressure. Each group carried out 4
FIGURE 3: KATICHAKRAASAN yoga asanas but in a different sequences. The data
analysis revealed that all the 4 groups showed
significant reduction in Systolic Blood Pressure
(p<0.05) immediately after performing yoga
asanas.
Interestingly, it was also observed that
Group C showed significantly more improvement.
The results of a study done by YOGA
ACHARYA MANDLIK (2008) also support the
result of current study. His aim of study towards
the effect of jalandhar bandha practiced properly
during the kumbhaka, on blood pressure (Systolic
& Diastolic). He observed that blood pressure
increases during the practice of kumbhaka. It is
also warned strictly in all Yogic Text to perform
FIGURE 4: TIRAYAKTADASAN all 3 bandhas during kumbhaka. According to him
while practicing the pranayama i.e. Kumbhaka, if
DATA ANALYSIS & RESULTS the jalandhar bandha is not performed properly,
the blood pressure will rise and it may lead to
permanent hypertension. Hence it is essential to
The data analysis reveal that there was a
perform the jalandhar bandha properly to keep the
significant reduction in the Systolic Blood
blood pressure on the lower side during the
Pressure with application of all the four groups
practice of pranayama with kumbhaka9.
immediately after performing yoga
The result of a study” Yoga package for
asanas(p<0.05), but analysis of
heart patients” done by Dr. JayantSohoni et al
variance(ANOVA) reveals that the mean
(1998) also support the result of current study. His
reduction in Systolic Blood Pressure between all
aim to study the effect of six months of regular
the four groups failed to achieve
practice of a package of selected yogic practices
significance(p<0.05).
on heart patients & stated that Yoga, the process
of being normalization, is studied since thousands
TABLE 1: TABLE SHOWING THE MEAN
VALUES OF PREASANAS SYSTOLIC BLOOD of years10. Hence we planned to study the effect of
PRESSURE WITHIN THE GROUP A, B, C & D. Yoga Training Package on heart patients. It is also
observed that the blood pressure and blood
Group A Group B Group C Group D
Pre 152.25 160.5 164 147.25 cholesterol reduced considerably. The patients
Post 138.25 133.57 147.75 133 experienced an overall relief of about 90%11.
Significance S S S S The result of a study done by McCfferey
S= significant (p<0.05)
NS= Non- Significant (p<0.05) R et al (1998) also support the result of current
study. His aim to determine the effectiveness of a
TABLE 2: TABLE SHOWING THE MEAN yoga program on blood pressure and stress, a
DIFFERENCE IN THE SYSTOLIC BLOOD group of hypertensive patients in Thailand were
PRESSURE WITH IN GROUP A, B, C & D. studied, with the experimental group showing
Group Group Group Group F significance significantly decreased mean stress scores and
A B C D value blood pressure, heart rate and body mass index
14.5 11 20.75 14.75 0.108 NS levels compared with the control group12.
The results of study done by Fortsch also
support the result of current study. His hypothesis
is Yoga and Medication will improve the
-----[48]-----
parameters of endothelial function. Systolic and effects like habituation & so on. For avoiding &
diastolic blood pressure, heart rate and body mass maintaining high blood pressure in control
index, fasting glucose, lipids, C-reactive protein “YOGA” took a big place.
and endothelial function were all studied as a Yoga stretches can benefit both the body
baseline and after 6 weeks of yoga practice. There & mind bringing energy & balance. It levels out
were significant reductions in blood pressure, physiological instability by relaxing & gently
heart rate and BMI in the total cohort of yoga13. stretches every muscle in the body, promoting
None of the laboratory parameters changed better blood circulation & oxygenation to all cells
significantly with yoga. For the total cohort there & tissues.
was no significant improvement in endothelial-
dependent vasodilatation with yoga training and CONCLUSION
meditation14.
The results of study done by Alexander 60 patients with hypertension within age
CR et.al, (1996) also support the result of current group 30-60year were taken & analysis showed all
study. His objective was to test the short-term the groups showed that there was significant
efficacy feasibility of 2 stress-reduction reduction of blood pressure irrespective of
approaches for the treatment of hypertension. The sequences adopted but Group C showed
study involved a follow-up subgroup analysis of a maximum beneficial effects but all the groups
3-month randomized, controlled, single-blind trial failed to achieve within the group significance.
conducted in a primary care, inner-city health (p<0.05)
center. Subjects were 127 African American men
and women, aged 55-85 years, with diastolic
pressure of 90-104 mm Hg and systolic pressure
ACKNOWLEDGEMENT
less than or equal to 179mm Hg. Of these, 16 did
not complete follow-up blood pressure I am thankful to all the subjects who
measurements. Women practicing the volunteered to participate in this study. I am
Transcendental Meditation technique showed thankful to the almighty, my parents, my brother
adjusted declines in systolic (10.4mm Hg, & sister and my husband Maj. Saurabh Kathait
P<0.01) and diastolic (5.9mm Hg, P<0.01) who always boosted my confidence and provided
pressures. Men in this treatment group also me constant support for finalizing this task.
declined in both systolic (12.7mm Hg, P<0.01)
and diastolic (8.1mm Hg, P<0.01) pressures REFERENCES
compared with control subjects. Effects of stress
reduction on blood pressure were found to 1. Richard gombrich, “theravada Buddhism: a
generalize to both sexes and diverse risk factor social history from ancient benares to modern
subgroups and were significantly greater in the Colombo.” Routledge and kegan paul,1988,
Transcendental Meditation treatment group5. page 44.
2. Alexander wynne, the origin of Buddhist
LIMITATION OF THE STUDY meditation, routledge 2007, page 51,56.
3. Swami ramdev, yogsadhana &
•The timing could not be analysed by this yogchikitsarahasya page no. 122-125.
method. 4. Alexander CN “ Trail of stress reduction for
•Find out at which level effects of yoga hypertension in older African Americans”
are seen. 1986 43(15):4.
Future scope of the study: 5. Dr Sujit Chandratreya in a study
•Study can be carried out for a longer “Hypertension & Yoga” 2006 22(12):10.
term effects. 6. Satyanandasaraswati, Asanas-Pranayama-
•Study can be carried out on post Mundra-Bandha. Published by Bihar Yoga
menppasual women who are hypertensive. Bharati, Munger, Bihar India.
•Study can be carried out with 2 different 7. Peter Crosta “Yoga an Easy Treatment for
methods included in it. Like breathing exercise Hypertension”. Yoga 20(3), 341-352 1981
and relaxation technique. Aug22.
8. The science Yoga Life, volume-5, Issue-2,
page-18.
IMPLICATION OF THE STUDY 9. Yogacharya Vishwas Mandlik “Effect of
Jalandhar Bandh on Blood Pressure”. An
Hypertension is prevalent by almost 40% experimental study, volume-82 2008 Oct. 2,
of all adult population. It can be because of many page-24.
things as a big example facing towards the 10. Susan lark “Yoga Relieve and Prevented
stressful life. Medication are available for high Eleevated Cardiovascular Risk Factor” 1986
blood pressure but it also comes with its adverse
-----[49]-----
September 12 115, 107-117. sixth edition. St louse, MO : mosby BP

11. Dr Jayantsohoni, et al “effect of yoga training 43:361-364, 2008.
on heart patients” 1999, 143, vol 5. 14. MMW Fortsch “stresss management in the
12. Mccaffrey R, et al. “the effects of a six-week treatment of essential arterial hypertension”
program of yoga and meditation on brachial 2006 34(7) :111.
artery reactivity” 2006, 32(1) :5-7. 15. Tenzin kyizom, et al. “influence of
13. Anderson, DougalasM, et al. mosby’s pranayamas and yoga asanas on hypertensive
medical, nursing, and allied health dictionary, patients” 2008.
-----[50]-----
TO STUDY THE EFFECT OF PROPIOCEPTIVE NEUROMUSCULAR

FACILITATION VERSUS WEIGHTED EXERCISES TO IMPROVE
STAIR CLIMBING TASK IN CHRONIC STROKE PATIENTS- A
COMPARITIVE STUDY
Bhatri Pratim Dowarah1, Arjun Singh Tanwar2
1.PhD Scholar, Srimanta Sankardeva University of Health Sciences, Guwahati, Assam
2.Physiotherapist, Alwar, Rajasthan
ABSTRACT:
OBJECTIVE: The objective of the study is to find out whether the Weighted Exercises (Stair Climbing Exercises) are
beneficial or the Proprioceptive Neuromuscular Facilitation is beneficial to improve stair climbing task in subjects with
chronic stroke.
DESIGN: It’s a comparative study design. A sample of 30 subjects was included in the study with a pretest and post test
study design. All the 30 subjects of hemiparasis was divided in two groups, (15 subjects each group), group A and group
B. The subjects of group A received normal control exercise program which includes Passive movement, Stretching
exercise and Active Exercises along with Stair Climbing Exercises. The subjects of group B treated with normal control
exercise program which consist of Passive Movements, Stretching Exercises and Active Exercises with, including P.N.F.
Data was taken on day zero, 45 and 90. Outcomes were taken according to Short Physical Protocol Battery and Duke
Mobility Skill Profile.
RESULT: The result of the present study demonstrated that there is a significant improvement in functional performance
activity of the lower extremity of the affected side. When two samples were conducted at the end of 45 days and after 90
days, it was found that there is significant improvement in functional activity in group A compared to Group B.
CONCLUSION: It has been recorded from the study that weighted exercise (stair climbing exercises) produces
significant improvement in stair climbing task in chronic stroke subjects. It can seen that use of weighted exercises in
patients with hemiplegia is beneficial. This can be used to enhance the functional outcome as well as strength in these
patients.
INTRODUCTON patient’s strength and avoid fatigue. Szymon

Pasuit et al- reported in the study that P.N.F helps
Stroke is a complex and devastating in reduction of spasticity. PNF has been used as a
disease. Despite treatment advances, stroke flexibility-treatment modality in rehabilitation
remains a leading cause of morbidity and after injury, surgery, and stroke (Voss, Ionta, &
mortality. 29% of stroke patients die within one Myers). Lee MJ, Kilbreath SL, Davis GM, Singh
year whereas 20% of these will die within 3 MF, Zeman B and Lord S- reported Progressive
months. Resistance Training significantly improves Power
Stroke or cerebrovascular accident is of leg muscles and Stair Climbing.
defined as a rapidly developing clinical sign of SL Morris, KJ Dodd, ME Morris- There
local or global disturbance of brain function is preliminary evidence that progressive
lasting more then 24 hours or leading to death due resistance strength training program reduce
to no reasons then the vascular origin. musculoskeletal impairment after stroke. Virgil
“WHO1999.” Aponte- reported Stair Climbing Exercises
Prevalence rate for hemiplagia in south improves Anaerobic Conditioning, Lower Body
India was reported to be 56.9- 100,000 as Strength, Power development and Flexibility.
compared to 150-186/1,00,000 population for Jozsi et al- reported power gains of
USA and Europe. approximately 10% to 30% in older men and
Chao-Chung Lee et al- reported that the women, by Weighted Stair climbing exercises.
P.N.F. approach results in a trend of batter Skelton et al- reported, in a study evaluating a
improvement on balance and functional mobility potential home based P.R.T., there is 18%
observed in patients with stroke. R.Y. Wang- improvement in leg extensor power. Moreland et
found that there is an improvement in gait speed al reported in the study, Conventional therapy vs
and cadence subjects with Hemiplegia, resistance exercise & conventional therapy
immediately after 1 session of P.N.F. and, was Rehabilitation inpatients, < 6 months since stroke,
further enhanced after 12 sessions. S.S. Adler, M. at discharge, resistance group exercised with
Buck- mentioned in their book that P.N.F. is an weights that were a mean 79–300% higher than at
integrated approach helps to patient, achieve their baseline. The increase was significant.
highest level of function and also increase
-----[51]-----
Improvements in Disability Inventory and 2- All the 30 subjects of hemiperesis with

minute walk test did not differ between groups. a duration between 6 month to 2 years and age
Sharp & Brouwer reported in their study- group between 60-80 years was taken.
At 6 weeks, flexion & extension strength Place of Study:
increased 16–154% on paretic side after resistive All the 30 subjects will be taken from
exercies.32Monger et al., 2002, reported in their various Physiotherapy OPD as per the criteria.
study- At 3 weeks, significant improvements were Sampling Method
demonstrated in Motor Assessment Scale sit-to- All the subjects will be taken by the
stand scores, walking speed, and timing of peak convenient sampling method based on initial base
vertical ground reaction force in response to line data and all the subjects will be referred by
resistive exercise. consultant Neurologist after diagnosis.
Kim et al found, improvement in stair Inclusion Criteria:
climbing and gait velocity in response to
isokinetic strength training. Weiss et al reported in  Chronic hemiperesis (male/female)
their study that there is decrease in chair stand  Arterial involvement both ischemic and
time by 21% and stair climb time is improved by hemorrhagic.
11%, due to strength training with weight  Age 60-80 years.
machines. Teixera Salmela et al used isometric,  Subjects with ability to walk.
ecentric and concentric exercises and found  Subjects will be taken on the basis of
42.3% increment in strength of paralytic limb, Short Physical Performance Battery Score
28% increase in gait velocity and 37.4% increase Sheet.
in stair climbing. Engardt et al done study on Exclusion Criteria:-
isokinetic training of knee extensor concentric
group and ecentric group, found concentric group:  Subjects who have any history of
25%-57% gains in concentricc strength, 13%- orthopedic disability or deformity.
17% increase in ecentric strength, ecentric group  Subjects using walking aids.
25%-30% increase in both concentric and ecentric  Subjects having functional odema.
strength.  Mentally instable patients.
The need of study is to find out whether  Subjects with Hearing Impairment.
Weighted Exercise or P.N.F. improves Stair Measurement Scales:-
Climbing Task in patient with post stroke
hemiperasis.  Short Physical Performance Battery.
The Aim of Study is to compare  Duke Mobility Skills Profile.
Proprioceptive Neuromuscular Facilitation and Time and Duration of the study:-
Weighted Exercise to improve Stair Climbing
All the 30 subjects of hemiparasis was
Task in Chronic Stroke Patients.
divided in two groups, (15 subjects each group),
OBJECTIVE OF STUDY group A and group B. The subjects of group A
received normal control exercise program which
•To find out the effect of Proprioceptive includes Passive movement, Stretching exercise
Neuromuscular Facilitation to improve Stair and Active Exercises along with
Climbing Task in Chronic Stroke Patient. Stair Climbing Exercises. The subjects
•To find out the effect of Weighted of group B treated with normal control exercise
Exercise to improve Stair Climbing Task In program which consist of Passive Movements,
Chronic Stroke Patient. Stretching Exercises and Active Exercises with,
•To find out any significant difference in including P.N.F. and Data was taken on day zero,
P.N.F. and Weighted Exercise to improve Stair 45 and 90.
Climbing Task in Chronic Stroke Patient. Protocol
RESEARCH APPROACH:- All the 30 subjects were assigned in two
groups and will be selected by convenient
To find out the statement of a problem sampling method on the basis of inclusion criteria.
for, Proprioceptive Neuromuscular Facilitation Group A subjects was treated with
versus Weighted Exercises to improve stair normal control exercise program which consist of
climbing task in chronic stroke patients. Passive Movements, Stretching Exercise and
Study design:- Active Exercises along with Weighted Climbing
It’s a comparative study design. A Exercise.
sample of 30 subjects was included in the study Group B subjects were treated with
with a pretest and posttest study design. normal control exercise program which consist of
Sample Design: Passive Movements, Stretching Exercises and
Active Exercises with, including P.N.F. Both the
-----[52]-----
two Groups were compared for better outcome TABLE 1: DATA ANALYSIS OF BALANCE
measures. SCORE BETWEEN GROUP A & B
Procedure DAYS GROUP A GROUP B t- P-
(N=15) M+ SD (N=15) M+SD VALUE VALUE
All the 30 subjects were divided into two DAY 0 3.33+ .72 3.40+ .74 -.250 .804
Groups and the treatment was given according to DAY 45 3.80+ .41 3.53+.52 1.560 .130
mentioned Protocol. DAY 90 3.93+.26 3.73+.46 1.474 .152
Proprioceptive Neuromuscular The result of the present study
Facilitation: demonstrated that there is a significant
15 subjects with Hemiperasis secondary improvement in stair climbing. When two
to Stroke will receive 30 min P.N.F. once in a day samples was conducted after 45th & 90th day
up to 12 weeks. The resistance was given to the using Short Physical performance Battery and
subject’s moving limb in one direction, as the end Duke Mobility Skill profile, It was found that
of the desired movement the action command was there is a significant improvement after 45th day
given to reverse direction, without relaxation, and with p =0.130, and shows no significant after
gives resistance to the new motion starting with 90th day in GROUP A compared to GROUP B
the distal part. p=0.152
Weighted Stair Climbing Exercise
It include Progressive Resistive Training TABLE 2 : DATA ANALYSIS OF GAIT SPEED
SCORE BETWEEN GROUPS A & B
by using Vast. In training resistance initially set to
80% of one repetition maximum (1 RM). Then DAYS GROUP A (N=15) GROUP B (N=15) t P
M+ SD M+SD
incremented by 2% of body mass per session. The 2.20+ .41 2.33+ .49 -.807 .426
DAY 0
subject was asked to wear weighted vast and then 2.53+ .52 2.60+.51 -.357 .724
DAY 45
climb-up and down stairs with weights, was 3.27+.46 2.73+.46 3.191 .003
DAY 90
included 10 flights of stair climbing with one
The result of the present study
minute of rest between each flight
demonstrated that there is a significant
improvement in Stair climbing. When two
samples was conducted after 45th & 90th day
using Gait speed score, It was found that there is
a significant improvement after 45th day with p
=0.724, and significant after 90th day in GROUP
A compared to GROUP B p=0.003
TABLE 3: DATA ANALYSIS OF CHAIR STAND

SCORE BETWEEN GROUPS A & B
DAYS GROUP A (N=15) GROUP B t P
FIGURE 1: SUBJECT DOING STAIR M+ SD (N=15) M+SD
CLIMBING EXERCISE DAY 0 1.67+ .49 1.60+ .51 .367 .716
DAY 45 2.07+ .59 2.07+.59 .000 1.000
DAY 90 3.33+.49 2.87+.52 2.544 .017

improvement in stair climbing. When two
using Chair stand score, It was found that there is
a significant improvement after 45th day with p
=1.00, and significant after 90th day in GROUP A
compared to GROUP B p=0.17
TABLE 4: DATA ANALYSIS OF STAIR

FIGURE 2: SUBJECT DOING STAIR ASCENT SCORE BETWEEN GROUPS A & B
CLIMBING EXERCISE
DAYS GROUP A (N=15) GROUP B (N=15) t P
M+ SD M+SD
Data Collection Process DAY 0 1.67+ .49 1.47+ .52 1.090 .285
Base line assessment was done on the DAY 45 1.73+ .46 1.60+.51 .756 .456
basis of primary performance and recording of all DAY 90 1.93+.26 1.73+.46 1.474 .152
outcome measures was carried out on the The result of the present study
following scales on day zero. demonstrated that there is a significant
1.Short Physical Performance Battery. improvement in stair climbing. When two
2.Duke Mobility Skill Profile. samples was conducted after 45th & 90th day
-----[53]-----
using Stair ascent score, It was found that there is FIGURE 5: MEAN CHAIR STAND SCORE OF
a significant improvement after 45th day with p GROUP A AND B
=0.456, and significant after 90th day in GROUP
A compared to GROUP B p=0.152
TABLE 5: DATA ANALYSIS OF STAIR

DESCENT SCORE BETWEEN GROUPS A & B
DAYS GROUP A GROUP B t P
(N=15) M+ SD (N=15) M+SD
DAY 0 1.27+ .46 1.13+ .35 .894 .379
DAY 45 1.40+ .51 1.13+.35 1.673 .105
DAY 90 1.67+.49 1.20+.41 2.824 .009

FIGURE 6: MEAN STAIR ASCENT SCORES OF
improvement in stair climbing. When two GROUP A AND B
using Stair descent score, It was found that there
is a significant improvement after 45th week with
p =0.105, and significant after 90th day in
GROUP A compared to GROUP B p=0.009
FIGURE 7: MEAN STAIR DESCENT SCORES

OF GROUP A AND B

FIGURE 3: MEAN BALANCE SCORE OF demonstrated that there is a significant
GROUP A AND GROUP B improvement in functional performance activity
of the lower extremity of the affected side in both
the groups.
DISCUSSION
In this study of moderate hemiplegia we
tried to assess the improvement in the strength of
paralytic limb to improve stair climbing task using
weighted exercise (stair climbing exercises) in
one group (group A) and PNF in other group,
along with normal control exercise program
FIGURE 4: MEAN GAIT SPEED SCORE OF which consist of passive movements, stretching
GROUP A AND B exercises and active exercises in both the groups.
In this study both the groups showed
significant improvement after receiving treatment
but mean score of group A (weighted exercise
group) showed grater improvement.
The weighted exercise (stair climbing
exercise) improves muscle strength through
increasing the size of the muscle. Some EMG
studies showed that as we trained to perform a
specific task (stair climbing), we learn to activate
our muscle more effectively for that task and
learning occurs relatively quickly. As a result, at
any time, the maximum strength that a subject
demonstrates during the task is a function, both of
neural control and muscle girth.
-----[54]-----
LIMITATIONS controlled trail. Arch Phys Med

Rehabilitation.
The study is done on immediate bases i.e. 12. Monger C , Cars JH, Flower V. Evaluation of
one repetition maximum is measured by lifting the home based exercise and training programme
maximum weight through squat; there is no any to improve sit to stand in patients with
equipment or method to check one repetition chronic stroke. Clinical Rehabilitation
maximum. The hemiplegics were of both sides 2002; 16 : 361-367
(right and left). It is known that right sided 13. Badics E., Wittmann A, Rupp M, Stabauer B,
hemiplegics usually have some perceptual Zifko U A. Systematic muscle building
disorder also is not consider in the study, but Exercise in the rehabilitation of stroke
nevertheless can affect the outcome. patients. Neuro Rehabilitation ; 17 (3) 211-4,
It has been recorded from the study that 2002.
weighted exercise (stair climbing exercises) 14. Teixeria – Salmela LF, Olney SJ, Nadeau S,
produces significant improvement in stair Browwer B. Muscle Skenythning and
climbing task in chronic stroke subjects. It can be physical conditioning to reduce impairment
seen that use of weighted exercises in patients and disability medicine Rehabilitation; 80
with hemiplegia is beneficial. This can be used to (10) : 1211 – 8, 1999 Oct.
enhance the functional outcome as well as 15. Diane Austin klien, William j Stone, Wayne
strength in these patients. Hence alternate T. Phillips, Jaime Gangi and Sarah Hartman.
hypothesis is accepted at p=0.00 and null PNF Training and physical function in
hypotheses is rejected. Assisted- Living Older Adults. Journal of
Ageing and Physical Activity, 2002,10,476-
REFERENCES 488
16. Kim CM, Eng JJ, Macintyre DL, Dawson AS.
1. Brain’s disease of the Nervous System. Sir Effects of Isokinetic strength training on
John Walton. 9th edition,193-194. walking in Persons with stroke. Stroke. 1997
2. “PNF in Practise” Susan S Adlar, Dominick ; 28(4) 722-28.
Beckers, Math Buck. 3rd Edition. 23-24 17. Weiss A, Suzuki T, Bean J,Fielding RA. High
3. Motor Control : Theories Practical Intensity strength training improves strength
Applications – Anne Shumway. and functional performance after stroke.
4. Steps to follow - The comprehensive 18. Teixeira – Salmela LF , Olney SJ, Nadeau S,
treatment of Patients with hemiplegia : PM Brouwer B. Muscle Strengthning and
Daviers . Second Edition. physical conditioning to reduce impairment
5. Stair Training Improves, stair climbing task and disability in chronic stroke survivors.
in chronic stroke patients – Lee MJ Arch Phys Med Rehabilitation 1999; 80 (10):
6. Mc.Comas AJ.Human neuromuscular 1211 – 18.
adaptations that accompany changes in active 19. Teixeira – Salmela LF, Nadeau S, Mc Bride
Med sci Sports Exerc 1994 ; 26 : 1498-1509 I, Olney SJ. Effects of muscle Strengthning
7. Gary L Smidt: Gait Rehabilitation, Churchill and physical conditioning training on
Livingstone, 254-258, 1990 temporal, Kinematic and Kinetic variables
8. Jonathan Bean, Seth Herman, Dank Kiely, during gait in chronic stroke survivors. J
Damien Callahan, Kelly Mizer, Walter R. Rehabilitation Med 2001; 33(2)
Frontera and Roger A. fielding ; Weighted 20. Engardt m, Knutsson E, Jonsson m, Sternhag
Stair climbing in Mobility – Limited older M. Dynamic Muscle strength training in
people : A pilot syudy. stroke pateints : Effects on Knee Extension
9. Virgil Aponate, MS: Develop Maximam torque, electromyographic activity and motor
strength, power, flexibility and conditioning function. Arch Med Rehabilitation 1995 ; 76
using just stair exercises. : 419 – 25.
10. Richard C, et al : Gait in sroke ; clinical in 21. Inaba M, Edberg E, Montgomerg J, Gills
geriatric medicine, vol.14 : no 4 MK. Effectiveness of functional training,
11. Moreland JD. Gold Smith CH, Huijibregts active exercise and resistive exercise for
MP, Anderson RE, eatal. Progressive patients with hemiplegia 53 (1) : 28 – 35.
Resistance strengthenig exercises after 22. Nadir Bharucha, Epidemiology of Stroke in
stroke: a single blinded rendomized India; National J.Southeast Asia 1998, 3:5-8.
-----[55]-----
EFFECTIVENESS OF MANUAL TRACTION OF TIBIO-FEMORAL

JOINT ON THE FUNCTIONAL OUTCOME IN KNEE JOINT
OSTEOARTHRITIS
Antony Leo Aseer P1, Iyer Lakshmi Subramanian2
1. Reader in physiotherapy,Sri Ramachandra University,chennai
2. Postgraduate in physiotherapy-Sri Ramachandra University,Chennai
ABSTRACT
The purpose of this experimental study is to analyze the effectiveness of manual traction on the pain, range of
movement and the functional outcome in knee joint osteoarthritis. Traction is an oldest form of treatment for deformity
correction, fractures and in treating disc prolapse. Very few studies are been performed to explore its effect in
peripheral joints but no studies are reported in an experimental design. Totally forty participants were randomized
into control and experimental groups. Baseline measurements of pain severity, active knee flexion range, Knee injury
and osteoarthritis outcome score (KOOS) were measured. The control group received treatment in the form of pain
relief modalities, exercises for muscle contractions and joint mobility. The experimental group received the same and
in addition manual traction in high sitting position. All the measurements were taken after two weeks of treatment.
There was significant improvement in experimental group compared to control group in terms of pain, subscales of
KOOS and moderate improvement in active knee flexion range. This study adds the importance of manual knee
traction, which is not commonly practiced for knee joint osteoarthritis. It further establishes traction as a means of
stretching shortened, tightened structures without increasing pain severity during and after treatment. Overall the
study also showed better improvements in functional outcome and in quality of life.
KEYWORDS: Knee, osteoarthritis, pain, active knee flexion, traction, KOOS.
INTRODUCTION into consideration, the functional restoration of

joint functions are incomplete. The most common
The knee joint is a common site of alteration in alignment of the osteoarthritic knee is
osteoarthritis of the tibio-femoral and patella- a varus deformity. This results in increased
femoral joints, possibly because of its exposure to forces in the medial compartment, which
trauma and serving as a major weight bearing creates a degenerative lesion of the medial
joint1. In Indian population KDJD older than 60 meniscus and subsequent degenerative changes
years is estimated to be 43% in women and 25% of the medial compartment. It’s one of the
in men. The prevalence is estimated to be 15% for commonest diagnostic radiological feature
women and 5% for men2. Primary osteoarthritis exhibiting medial joint space narrowing3. In
has no known etiology; secondary osteoarthritis advance stages, the cartilage is completely worn
can be traced to abnormal joint mechanics. out, exposing the bony ends, approximating each
Abnormal knee mechanics produce secondary other leading to joint replacement surgery.
changes in the articular cartilage, subchondral It is strongly believed that all therapy
bone, and supportive structures of the knee. related treatment approaches follow the principles
Previous injury of soft tissues may be complicated of joint mechanics. When an altered mechanics is
by subsequent degenerative changes. noted, therapist employs a manual way of
Osteoarthritis may be a physiologic response to correcting it terming as manual therapy or
repetitive, longitudinal impulse loading of the mobilization techniques. There are very few
joint. Changes may involve the medial or lateral studies providing evidence on the efficacy of
tibio-femoral compartment, the patella-femoral manual therapy of lower extremities4.
joint or involving all three areas. Studies related to manual techniques in
The sequelae of knee joint degeneration knee osteoarthritis have suggested that
leads to pain, movement restriction, reduced combination of manual physical therapy and
muscle efficiency, alerted walking pattern, supervised exercise yields functional benefits for
excessive energy expenditure, impaired joint patients with osteoarthritis of the knee and may
functions and overall affecting the quality of life. delay or prevent the need for surgical
Basically the treatment approach towards knee intervention5. The type of manual techniques
osteoarthritis involves reducing the joint varies with therapist ranging from glides to
inflammation, joint protection, training the distraction. The factors include direction of glide,
weakened muscles and regaining the functional force, magnitude, time period of sustaining glide,
mobility of knee joint. As like any other joint, distraction force, duration etc. Many studies have
knee joint degeneration too has a mechanical focused on application of anterior/posterior
cause. Until unless the mechanical cause is taken glides, patellar glides to improve functional
-----[56]-----
outcomes4. In a comprehensive rehabilitation Study design

program of knee osteoarthritis, manual therapy The study design is a single blinded,
program helps to regain mobility and function6. randomized controlled trail using simple
Outcomes of therapy are analyzed using randomization. All participants are randomly
functional outcome measures as like timed up and allocated to control and experimental group.
go walk test4 step functions7, osteoarthritis index8
and knee osteoarthritis outcome survey. The drive Outcomes
for standardized instruments of outcome measures After screening process, a verbal
in practice not only considers the measurement of explanation of the study protocol is made. An
body function impairment (e.g.; strength, range of informed consent is obtained for authorizing their
motion) but also should consider patient’s point of participation in the study. The evaluation includes
view on activities of daily living and life patient profile (age, gender, hospital identity
participation9. Self-report measures assess the number) were recorded. Knee joint specific
patient perspective on his/her ability to perform a evaluation includes 1) Severity of Pain measured
task (Western Ontario and McMaster Universities using visual analog scale 2) Knee joint flexion
Osteoarthritis Index (WOMAC), Knee injury and mobility using goniometer 3) Knee functions
Osteoarthritis Outcome Score (KOOS) whereas outcome using KOOS. The sub-scales include
performance based measures capture the patient symptoms, stiffness, functions-daily living,
ability to perform a certain task10. sports, recreation activities and quality of life. The
The treatment module of passive glides, measurements are measured at baseline and two
mobilization helps in regaining the movement weeks after intervention.
deficit of the joint but not addressing the joint Procedure
space narrowing. Traction is one such way of
mobilization in practice for long many years. A A total number of forty five participants
very recent case series in 2010 have analyzed that were enrolled for the study, in which four of them
manual traction mobilization to knee joint in did not meet the inclusion criteria and one was not
patients with pain and movement dysfunction willing to take part. A sample of forty participants
have not been assessed over time11. Of the passive were selected and randomly allocated to control
treatment techniques advocated by Kaltenborn and experimental group. The initial evaluator
(1986) and Schneider (1988) traction is a well measured the baseline knee joint specific
suited technique for treating pain with grade 2 or measures and post intervention. The principle
3. The primary treatment effect is to stretch the evaluator administered the manual therapy
periarticular soft tissues, increased mobility of techniques, pain control modalities and prescribed
hypo mobile joints and overall distraction at the exercises. The evaluators were blinded of the
narrowed medial joint space. The effectiveness of group allocation and test results respectively.
traction is well studied in vertebral column and Both the Control group and experimental
upper extremity and the most under studied aspect group received the same line of management as
in lower extremities4. Therefore the purpose of referred but in turn the experimental group also
this experimental study is to analyze the effects of received manual traction of knee joint. For pain
traction on pain response, mobility status and relief, interferential therapy was given with two
functional outcome in knee osteoarthtic patients. electrodes placed over the sides of knee joint for
duration of fifteen minutes. A proper conducting
medium is used. Isometric contractions of
MATERIALS AND METHODS quadriceps, active mobility exercises in high
sitting and in prone lysing are performed and
The experimental study was approved by
educated to practice at home.
the Head of Physiotherapy Department, Sri
Ramachandra Hospital, Chennai. Manual therapy intervention
Participants Distraction in sitting12
The participant is seated on the edge of
The participants were selected from the
the couch with toweling supporting the underside
outpatient physiotherapy department as a sample
of the distal thigh. A trained manual therapist with
of convenience. The inclusion criteria for the
good expertise performed the procedure. The
study were 1) Knee pain with limitation in range
therapist stands at the participant’s side facing the
of motion 2) diagnosed to have knee joint
patient’s feet so as to direct his forearms in the line
osteoarthritis 3) Radiograph showing medial joint
of force. A long axis distraction is produced by
space narrowing. Exclusion criteria included
leaning forward with the trunk. It is performed in
individuals 1) acute infective arthritis 2) history of
knee joint at ninety degree of flexion. This
previous trauma, unhealed fractures 3)
technique is used as general mobilization to
Neurological disorders 4) Referred pain from low
increase tibio-femoral joint paly for pain
back region.
control.to sustain the effect of distraction an
-----[57]-----
alternate method of sling is wounded around ankle On comparing the side of involvement,
with stirrup attachment for placement of therapist 50% showed right knee involvement and 42.5%
foot to apply distraction. This allows the therapist has left knee involvement (Table 2)
to palpate the joint space as the distraction is
applied. The intervention was applied TABLE-1 PATIENT DEMOGRAPHICS
continuously for 30 seconds followed by a 10 Std. Sig. (2-
GROUP N Mean
second rest period. The sequence was repeated 4 Deviation tailed)
times, for a total of 2 minutes of traction Control 20 59.10 11.073
AGE .598
Experimental 20 57.35 9.691
mobilization per session. Each participant
received three sessions in a week and overall of 6
TABLE-2 FREQUENCY AND PERCENTAGE OF
sessions of manual distraction for a 2 week period. SIDEDNESS
DATA COLLECTION GROUP
Control Experimental Total
(%) (%)
The data collection starts at baseline Left Count 8 (40.0) 9 (45.0) 17 (42.5)
comprising patient profile, pain severity using Right Count 12 (60.0) 8 (40.0) 20 (50.0)
visual analog scale (VAS), range of motion of Bilateral Count 0 (0) 3 (15.0) 3 (7.5)
knee joint using standard goniometer and KOOS The mean value for pain severity (VAS)
questionnaire. The VAS has a test-retest for the control group was 6.70 and after
reliability ranging from 0.71 to0.9913. The intervention the mean value of VAS was 5.25.The
standard goniometer has high intra-tester pain severity noted to be declined at a difference
reliability and validity14. KOOS is a validated of 1.45. The mean value for pain severity (VAS)
outcome instrument for treatment effects in knee for the experimental group was 6.85 and after
osteoarthritis15. The inter class correlation intervention the mean value of VAS was 4.00.The
coefficients were over 0.75 for all subscales and pain severity noted to be declined at a difference
this indicates needed test-retest reliability. Post of 2.85.The differences in pain severity was
intervention values are got after 2 weeks of statistically significant in experimental
intervention. The process of data analysis consists group(p<.01)and no differences were noted in
of baseline comparison between control and control group.
experimental groups, post treatment assessment The mean value for knee flexion range
between groups, pre and post treatment for the control group was 118.25 and after
comparison of various variables in control and intervention the mean value of flexion range was
experimental group. The effectiveness of manual 119.75.The ROM noted to be minimally increased
traction on pain, range of motion and functional about 1.50. The mean knee flexion range for the
outcome was analyzed using inferential statistics experimental group was 118 and after intervention
(two-tailed test). The data analysis was done using the mean value increased to 123.50.There is no
SPSS and statistical significance level was set. significant changes in knee flexion after
intervention in both the groups (p<.001).In
experimental group, there is a significant
RESULTS
difference in knee flexion ROM(p<.01)
On analysis of each subscales of KOOS
The study on forty participants with 14
in control group, noted significant differences in
males and 26 females participated in this
subscale for pain, symptoms & ADL(p<.001)and
experimental study. Finally all forty participants
subscale of sports & recreation showed significant
were followed up till the end of the study and were
differences(p<.05).Whereas in experimental
able fulfill to measure all the variables (n=20).The
group, all the subscales of KOOS were found to
mean age for all participants in control group is
be significant(p<-001).
59.10 and in experimental group is 57.35(table 1).
Overall, all the variables of knee joint
All the participants were regular for follow up and
specific measures have found to be improved and
there is no missing data.
statistical differences were noted in experimental
group then control group.
-----[58]-----
TABLE-3COMPARISON OF PRE AND POST VALUES BETWEEN CONTROL AND EXPERIMENTAL

GROUP
PRE POST
VARIABLES GROUP N Sig. (2-tailed) Sig. (2-tailed)
MEAN±SD MEAN±SD
Control 20 6.70±1.174 5.25±1.482 .010
VAS .689
Experimental 20 6.85±1.182 4.00±1.451
Control 20 118.25±12.169 119.75±11.751 .373
ROM .960
Experimental 20 118.00±18.238 123.50±14.428
Control 20 62.1400±11.19779 68.2095±9.75733 .001
K_SYMP .593
Experimental 20 64.4610±15.69518 79.7955±10.98334
Control 20 57.2060±9.25045 63.1740±7.85522 .004
K_PAIN .267
Experimental 20 53.7305±10.24725 70.8080±7.83044
Control 20 65.9505±8.49905 69.33±8.230 .008
K_ADL .140
Experimental 20 61.7595±9.07849 76.24±7.448
Control 20 40.75±23.579 44.75±26.030 .006
K_S&R .859
Experimental 20 42.00±20.417 63.50±12.886
Control 20 55.3125±5.83314 57.9250±4.74972 .003
K_QOL .286
Experimental 20 52.1875±11.51997 61.8750±2.79508
functional outcome, leaving no differences in

other variables.
Osteoarthritis has been largely
investigated for pharmacological effects and
physical therapy modalities including exercise.
Much less emphasis has been placed on the
manual therapy approaches. The treatment
technique of manual traction to knee joint is not a
common principle of practice. Generally traction
is applied to vertebral joints and the similar
physiological effects are expected at the knee joint
FIGURE 1: PRE AND POST TREATMENT
also. The results indicated that the long axis
COMPARISON ON VARIOUS VARIABLES IN distraction technique was successful in reducing
CONTROL GROUP self-reported present intensity of osteoarthritic
knee pain in the short-term and that this change
was statistically significant when compared with
a control group. This change in short term pain
reduction was also reported16, who also applied
manual therapy for osteoarthritic knee. Previous
studies17,18 reported improvement with exercise
have ranged from 8% to 27% decreases in pain
and 10% to 39% improvements in function.
The role of manual traction in range of
knee flexion is noted to be increased compared to
the control group. The increment in knee flexion
range is not noted exemplary but compared to the
FIGURE 2: PRE AND POST TREATMENT baseline value a difference in ROM is noted. This
COMPARISON ON VARIOUS VARIABLES IN finding goes in accordance to Sara Maher’s study
EXPERIMENTAL GROUP reported on significant change in passive knee
flexion.
DISCUSSION In physical therapy practice, a valid
functional outcome questionnaire is needed to
The study to analyse the effectiveness of measure the net effects. KOOS was found to an
manual knee traction on the various knee specific easy tool to administer and it is an extension of
variables were analysed. It revealed that there is a WOMAC. All the subscales showed good
significant decrement of pain severity, minimal improvement in functions as in intervention
differences in improvement of knee flexion range group. A very similar type of study by Gail D in
and improvement noted in overall functional 2000 showed improved WOMAC values
outcome following six sessions of manual knee following manual therapy in knee. Overall manual
traction. The conventional physiotherapy knee joint traction showed better improvements in
management group showed decrement in pain terms of pain relief, increased range of flexion and
severity and pain, symptoms, ADL subscales of better functional outcome.
-----[59]-----
As clearly quoted, any mechanical REFERENCES

dysfunction need to be corrected through
mechanical means. Hence manual therapy in the 1. Mankin HJ: Articular cartilagc, cartilage
form of traction tends to distract the joint at the injury and osteoarthritis. In Fox JM, Del
articular surface level. The mechanics involved in Pizzo W (eds ): TI,e Patellofemoral joint.
long axis traction is designed to distract the knee New York, McG ra w-HiLI , 1993:442 .
and assist in pulling the shortened soft 2. Bharat S Mody, Orthopedics Today.
tissues(ligament, capsule).The maneuver may July/august 2010.
temporarily decrease joint compression allow 3. Kellgren JH, Lawrence JS. Radiological
sufficient fluid mechanics19. However, this assessment of osteoarthrosis. Ann Rheum
procedure requires intact ligamentous and Dis. 1957; 16:494-501.
capsular structures to operate successfully. It also 4. Moss P, Sluka K, Wright A. The initial
requires practice by the practitioner to acquire the effects of knee joint mobilization on
motor skills necessary to perform the procedure. osteoarthritic hyperalgesia. Man Ther 2007;
The study consisted of 3 treatments per 12: 109–18.
week for 2 consecutive weeks, a total of 6 5. Gail D Deyle,Nancy
treatments that produced significant self-reported Henderson.Effectiveness of manual physical
pain relief and improved functions and quality of therapy and exercise in osteoarthritis of the
life. In the near future estimating the relationship knee-A RCT.Annals of internal medicine.
between dosage and outcome pertaining to the February 1, 2000 vol. 132 no. 3 173-181.
present study can be analysed. 6. Prentice WE. Techniques of manual therapy
The Preliminary findings of this study for the knee. Journal of Sports Rehabilitation.
promote future research for manual therapy 1992; 1:249-57.
protocols being incorporated with exercise 7. van den Dolder PA, Roberts DL. Six sessions
regimes in the management of knee joint of manual therapy increase knee flexion and
osteoarthritis. Large Randomised clinical trials improve activity in people with anterior knee
should also attempt to address the dosage and pain: a randomized controlled trial. Aust J
duration of treatment required to resolve or Physiother 2006; 52: 261–4.
manage a condition. 8. Deyle GD, Henderson NE, Matekel RL, et al.
The greater improvement compared with Effectiveness of manual physical therapy and
results of previous studies may be due to the exercise in osteoarthritis of the knee. A
manually applied treatment, which allowed the randomized, controlled trial. Ann Intern Med.
therapist to focus treatment on the specific 2000;132(3):173–181.
structures that produced pain and limited function 9. Their.SO.Forces motivating the use of health
for each patient. status assessment measures in clinical
settings and related clinical research.Med
LIMITATIONS Care. 1992 May;30(5 Suppl):MS15-22.
The limitations include a small sample 10. Piva SR, Fitzgerald GK, Irrgang JJ, Bouzubar
size and short term follow up of findings. The F, Starz TW. Get up and go test in patients
results reveal that better outcome following with knee osteoarthritis. Arch Phys Med
manual knee traction is only short term responses Rehabil. 2004 Feb; 85(2):284-9.
and long term analysis is needed. On the technical 11. Sara Maher,Doug Creighton,Melodie
context, treatment technique is applied in one Kondratek. The effect of tibio-femoral
position (high sitting) and other positions as like traction mobilization on passive knee flexion
prone lying traction can be carried out. motion impairment and pain: a case series. J
Man Manip Ther. 2010 March; 18(1): 29–36.
12. Kaltenborn FM. Manual mobilization of the
CONCLUSIONS
joints. 6th ed. Oslo: Olaf Norlis Bokhandel;
2002.
The study concludes and lends support
13. Finch E, Brooks D, Stratford PW. Physical
for the use of manual knee traction or distraction
rehabilitation outcome measures: a guide to
of tibio-femoral joint in improving the overall
enhance clinical decision making. 2nd ed
functional outcome in knee osteoarthritis. This
Hamilton, Ont.: Canadian Physiotherapy
study also highlights the importance of manual
Association; 2002.
techniques in restoring the altered mechanics
14. Gogia PP, Braatz JH, Rose SJ. Reliability and
occurring in knee joint pathologies. Hence the
validity of goniometric measurements at the
study supports the use of manual traction in
knee. Phys Ther 1987;67: 192–5.
rehabilitating knee joint arthritis.
15. Ewa Roos M,Knee injury and osteoarthritis
outcome score(KOOS)-validation and
comparision to WOMAC in total knee
-----[60]-----
replacement.Health and quality of life 116:529-34.

outcomes.2003,1:17. 18. Ettinger WH Jr, Burns R, Messier SP,
16. Henry Pollard,Graham Ward.The effect of Applegate W, Rejeski WJ, Morgan T, et al. A
manual therapy knee protocol on randomized trial comparing aerobic exercise
osteoarthritic knee pain-A RCT. J Can and resistance exercise with a health
Chiropr Assoc. 2008 December; 52(4): 229– education program in older adults with knee
242. osteoarthritis. The Fitness Arthritis and
17. Kovar PA, Allegrante JP, MacKenzie CR, Seniors Trial. JAMA. 1997; 277:25-31.
Peterson MG, Gutin B, Charlson ME. 19. Nordin M, Frankel V. Basic biomechanics of
Supervised fitness walking in patients with the musculoskeletal system. 2nd ed.
osteoarthritis of the knee. A randomized, Philadelphia, PA: Lea & Febiger; 1989.
controlled trial. Ann Intern Med. 1992;
-----[61]-----
DOES POLARIZED LIGHT THERAPY IMPROVE CHRONIC

MAXILLARY RHINOSINUSITIS?
Ashraf Hassan Mohammed*, Anees G.Saleh*, and Zizi Mohammed Ibrahim*
*Lecturer of physical therapy department for surgery, Cairo University
ABSTRACT:
PURPOSE: The current study aimed to determine the effectiveness of polarized light on chronic rhinosinusitis.
METHODS: Forty patients of both sexes (18 male and 22 female) suffering from chronic rhinosinusitis participated in
this study, they were divided randomly into two equal groups. Group (I) treated by placebo polarized light and medical
care, while the second group (II) was treated by polarized light and the same medical care as the first group. The
treatment course extended up to 4 weeks, the session extended for 10 minutes and applied day after day, evaluation was
carried out by the sinusitis symptom score (SSS), assessment was performed before starting the treatment and once more
after 4 weeks, paired t test was used to assess the gained results, and the probability value of <0.05 was considered
significant.
RESULTS AND CONCLUSION: The statistical analysis of the gained results revealed that polarized light therapy was
an effective treatment for reducing symptoms of chronic maxillary rhinosinusitis, as evidenced by high decrease in
sinusitis symptom score.
KEYWORDS: Chronic maxillary rhinosinusitis, polarized light, and sinusitis symptom score.
INTRODUCTION pain, cough, and ear pain mix figure 1. The minor
symptoms achieve diagnostic significance when
Fluid mechanics is a branch of one or more of the major symptoms are present.
biomechanics study the mechanical behaviour of Nasal obstruction or posterior discharge is usually
fluids inside the human body either blood vessels the main complaint in patients with CRS3.
(arteries and veins), organs as (heart and lung) or
cavities as the sinus. As result, there are two types
of fluid flow inside the human body, laminar and
turbulent flow. The laminar flow occur when
object move with low velocity relative to fluid
medium and it is characterized by smooth layers
of fluid molecules flowing parallel to one another.
While the turbulent flow occur when object move
with high velocity relative to fluid medium and
the layers of fluid near the surface of object.
Nature of human body has arranged that the flow
in normal condition is laminar while in
FIGURE 1: THE FLOOR OF THE MAXILLARY
pathological condition is turbulent1.
SINUS IS CLOSELY RELATED TO THE ROOTS
The mechanics of rhinological diseases OF THE SECOND PREMOLAR AND FIRST
as allergic rhinitis, polyposis, vasomotor rhinitis, MOLAR TEETH. THIS CREATES A
nasal hyper reactivity and chronic sinusitis is very POTENTIAL ROUTE FOR THE SPREAD OF
important to understand to put the proper line of DENTOGENIC INFECTIONS, AND A TOOTH
treatment either conservative or surgical2. EXTRACTION MAY CREATE A
Chronic rhinosinusitis (CRS) is a COMMUNICATION BETWEEN THE ORAL
common long term condition and a significant CAVITY AND MAXILLARY SINUS4
health and socioeconomic problem. It negatively
affects the quality of life, might impair function, Sinusitis is one of the most common
and results in reduced work place productivity. health care challenges in the United States. The
The etiology of CRS is multifactorial (e.g. viral, incidence of sinusitis in the United States, as per
bacterial or fungal infection, allergy, and national census data, has been estimated at 14.1%
environmental factors). The definition of CRS is of the adult population. According to the
based on signs and symptoms. The major American Academy of Otolaryngology, this
symptoms of sinusitis are facial pain, pressure, condition leads to direct health care costs of $ 3.4
nasal obstruction, nasal drip, hyposmia (weakness billion per year and chronic sinusitis alone results
and disturbance of smell), purulence in nasal in 18 to 22 million US physician office visits
cavity on examination, and fever with acute annually5.
episodes. While minor symptoms include CRS has a substantial negative health
headaches, halitosis (bad breath), fatigue, dental impact with respect to mood, body pain, energy
-----[62]-----
level, physical functioning. In some domains of acute and chronic inflammatory reactions. The
general health medically resistant chronic use of polarized light in the treatment of wounds
sinusitis is substantially more debilitating than accelerates wound closure and from
angina, congestive heart failure, chronic biomechanical point of view increases tensile
obstructive pulmonary disease, and chronic back strength of scars11.
pain or sciatica. CRS impacts both patients and the Bioptron light therapy is ideally suited as
health care system, requiring repeated physician a complementary treatment in rehabilitation. It is
office visits, prescription medications, over the often required with standard physio-therapeutic
counter medications, and surgical therapy6. procedures and it can be successfully used as an
Rhinovirus is the most common viral integral part of complex physio-therapeutic
pathogen and is easily transmissible. procedures for sports injuries, burn, ankle and
95% of individuals challenged with knee injuries, as well as inflammatory
intranasal rhinovirus drops became infected, and conditions12.
three quarters of them became symptomatic.
Within 10 hours, newly replicating virus was METHODS
found in the nasal secretions. As confirmed by
sinus puncture, Streptococcus pneumoniae, Forty volunteers suffering from chronic
Haemophilus influenza, and Moraxella catarrhalis maxillary rhinosinusitis, of both sexes (18 males
make up the majority of the community acquired and 22 females), and their age ranged from 35 to
bacterial pathogens. One possible mechanism for 45 years, they were divided randomly into two
introduction of pathogens from the nasal passages equal groups. The placebo group (GI), was treated
into the sinuses may actually be through nose by placebo polarized light therapy (10 min, day
blowing. From biomechanical point of view and after day for 4 weeks), in addition to the routine
in relation to the fluid mechanics, this process medical care, while the treatment group (GII) was
creates a negative intra nasal pressure with such treated by polarized light therapy (10 min, day
force that nasal fluid is propelled from the middle after day for 4 weeks) in addition to the routine
meatus into the sinus cavity7. medical care ).
Distinguishing CRS from conditions
with similar symptoms is difficult but important. Inclusion criteria:
Using CT imaging as the criterion standard, the -All patients suffer from chronic maxillary
true prevalence of CRS in patients referred for sinusitis.
evaluation of potential CRS based on patient’s -Both sexes were involved.
reported symptoms ranging from 65% to 80%8. -Their age ranged from 35 to 45 years old.
This prevalence may be accompanied by Exclusive criteria:
headache, fever, cough, halitosis, fatigue, dental
pain, and other nonspecific signs or symptoms, the -Pregnancy
differential diagnosis of CRS includes allergic -Immune deficiency diseases as AIDS.
rhinitis, non allergic rhinitis, nasal septal -Respiratory diseases as chronic obstructive
deformity, vasomotor rhinitis, and non rhinogenic pulmonary diseases (COPD).
causes of facial pain. The later include neurologic -Patients with photo sensitivity.
disorders, such as vascular headaches, migraine, -Patients with Hay fever (allergic rhinitis).
trigeminal neuralgia, and other facial pain -Patients with common cold, tooth ache, or cough.
syndromes9. -Patients with life threatening disorders as renal
Use of intra nasal saline has been shown failure.
to decrease nasal symptoms and improve quality Assessment: Sinusitis Symptom Score
of life in allergic rhinitis and CRS. Also nasal (SSS) was used to assess the improvement of
saline irrigation mechanically rinses away cases; assessment was carried out before starting
predisposing agents such as aeroallergens like the treatment and once more after finishing the
pollen, and dust. Intra nasal corticosteroids have course. It involves the most common symptoms of
been shown to relieve symptoms in CRS, but it is sinusitis including; facial pain, post-nasal drip
unclear if this is due to simply a decrease in nasal (PND), nasal obstruction, nasal discharge (ND),
congestion or to decreased inflammation in the hyposmia (smell weakness and disturbance), and
sinuses themselves. Corticosteroids have multiple cough. And each symptom ranges from absent (
immune modulator mechanisms. Topical nasal 0), mild (1), moderate (2), or sever (3); and each
corticosteroids are a very effective form of patient has to identify his degree on this scale13.
treatment for allergic rhinitis and CRS10.
Polarized light has a selective effect on RESULTS
various cells of the immune system, as well as
other biological model systems. It plays a Statistical analysis of the pretreatment
selective cell specific role in the regulation of results of both groups revealed no significant
-----[63]-----
difference between them as shown in table (1) as improvement of symptoms in the treatment group
well as in figure 2. than that of the placebo group as explained in table
(3) as well as in figure (4).
TABLE 1: STATISTICAL ANALYSIS OF SSS
PRETREATMENT FOR BOTH GROUPS TABLE 3: STATISTICAL ANALYSIS OF SSS
Placebo group (GI) Treatment group (GII) POST- TREATMENT FOR BOTH GROUPS
Mean 17.4 17.6
± SD 0.88 0.89 Placebo group (GI) Treatment group (GII)
SE 0.19 0.189 Mean 17.5 7.5
t. value 0.71 ± SD 0.83 1.3
p. value 0.65 SE 0.18 0.3
Significance Non- significance t. value 6.3
p. value 0.002
Significance Significant
FIGURE 2: MEAN VALUES OF SSS PRE-

TREATMENT FOR BOTH GROUPS.
FIGURE 4: MEAN VALUES OF SSS POST-
The statistical analysis of pre and post treatment TREATMENT FOR BOTH GROUPS
results for the placebo group revealed non
significant difference (p>0.05). On the other hand DISCUSSION
the statistical analysis of the gained results for the
treatment group pre and post treatment clarified a Altland, 2005; reported significant
marked reduction of symptoms and showed a effects of polarized light therapy in relieving
significant improvement (p<0.05), as revealed in symptoms and signs of chronic rhinosinusitis
table ( 2) and figure (3). particularly nasal discharging as well as facial
pain14.
TABLE 2: PRE AND POST RESULTS OF SSS Medenicaand, 2004; approved that;
FOR EACH GROUP. visible light therapy could improve the symptoms
Placebo group Treatment group of allergic rhinitis and sinusitis and might serve as
Pre Post Pre post a novel treatment modality. Additional insight
Mean 17.5 17.55 17.45 7.1
± SD 0.888 0.825 0.887 1.209
into the mechanisms of action, short term and
SE 0.198 0.184 0.1983 0.2705 long-term effects, and adverse events are
t. value 1.0 -23.5 needed15.
p. value 0.33 0.001
Significance Non Significant Significant
Results of the current study revealed
that; there was non-significant difference between
the pre and post-treatment means for the placebo
group (p>0.05).While the pre and post
measurements of the treatment group revealed a
significant improvement of SSS (p<0.05), and
such results were supported by the work of
Webster, 200516.
As well as there was non-significant
difference in means of pretreatment measures for
both groups (p>0.05).
On the other hand the comparison of both
groups after treatment revealed a significant
FIGURE 3: MEAN VALUES OF PRE AND POST improvement in the treatment group than that of
RESULTS OF SSS FOR EACH GROUP. the placebo group (p<0.05), and these results are
in parallel with that of Spector, 200817.
On the other hand the statistical analysis The significant improvement of
of both groups post-treatment showed a symptom is on line with the work of Nagi, 200518,
significant difference with a clinical and statistical who approved a high effect of intranasal photo
-----[64]-----
therapy than fexophenadine HCL in reducing 7. Roxanne S. L, and Rohit K. The Diagnosis
clinical symptoms of seasonal allergic rhinitis. and Management of Acute and Chronic
Such significant improvement gained by Sinusitis. Prim Care Clin Office Pract. 2008;
polarized light therapy (BLT) might be attributed 35: 11–24
to the biostimulative effects of BLT, which are the 8. Csoma RW,LevittAJ,and Levitan RD. A
results of synergy between different mechanisms randomized Controlled Tria1 of the
of action as; improves microcirculation, Effectiveness of light therapy and Fluoxetine
harmonizes the metabolic processes, reinforces in patients with winter seasona1Affective
the human defense system, stimulates Disorder .Am J Psychiatry 2006 .63(5):805-
regenerative process of the entire organism, 12.
promotes wound healing, relives pain or decreases 9. Denburg JA, Snyderman CH., and Carrau
its intensity and general wellbeing. BLT leads to RL. Chronic Rhinosinusitis. Immunol
stimulation of neoangiogenesis, increasing Allerggy Clin North AM. 2004; 24(1):165-
phagocytosis, stimulation and activation of ATP 178.
production, enhancement of important specific 10. Williamson IG, Moore MJ, and Smith PW.
enzymes involved in cell regeneration, increasing Antibiotics and Topical Nasal Steroid for
the activity and production of collagen, and Treatment of Acute Maxillary Sinusitis: A
reducing the excitability of nervous tissue18,19. randomized Controlled Trial. JAMA 2007;
298(21): 2487-96.
CONCLUSSION 11. Kubasova TA, Fenyo MH, and Gazso LK.
Investigations on Biological Effect of
It could be concluded that our results Polarized Light. Photochemistry ad
support the expectations that polarized light Photobiology 2008; 48: 505-509.
therapy had valuable effects in treating chronic 12. Lubart RH, Garage AH, and Rochkind ST.
rhinosinusitis as evidenced by the significant Towards a Mechanism of Low Energy
decrease in SSS. The application of the Bioptron Phototherapy. Laser therapy 2005; 3: 11-13.
light therapy is easy, safe, and non-invasive for 13. Meltzer EQ, Hamilos DL, and Hadley JA.
such patients, induced greater improvement of Rhinosinusitis; Establishing Definitions for
signs and symptoms of chronic rhinosinusitis. Clinical Research and Patient Care.
Otolatyngol Head NechSurg 2004; 131(1):
S1-S62.
REFERENCES 14. Altland OD, Dalecki DN, and Francis CW.
Low Intensity Ultra sound versus Polarized
1. Nordin M, Frankel VH. Basic Biomechanics Light Therapy and the Chronic
of the Musculoskeletal System. 3rd ed. Rhinosinusitis. Polarized Light Med Biol.
Philadelphia: 2001Lippincott Williams & 2004; 2(11): 23-31.
Wilkins; p: 467-480. 15. Medenica LA, and Lens MF. Pressure Ulcers
2. Steve Helms, ND, Alan L., and Miller ND: and the Polarized light Therapy. J. wound
Natural Treatment of Chronic Rhinosinusitis care 2004; 10:30-55.
Alternative Medicine Review 2006; 11 16. Webster P, Sanclement JP, and Thomas J.
(3):196-207. Photodynamic Therapy Effect on Micro
3. Aukema AA, Mulder PG, and Fokkens WJ. organisms in Surgical Specimens of Patients
Treatment of Nasal polyposis and Chronic with Chronic Rhinosinusitis. Laryngoscope
Rhinosinusitits with Fluticasone Propionate 2005; 115:578-582.
Nasal drops Reduces Need for Sinus surgery. 17. Spector SL,Bernstein IL, and Li JT.
J. Allergy Clin. Immunol. 2004; Parameters for the Diagnosis and
115(5):1017-1023. Management of Sinusitis by Phototherapy. J
4. Bolger WE, Butzin CA, and Parsons DS. Allergy clinimmunol 2008; 102:S107-S144.
Anatomy of the Paranasal Sinus in Diseases 18. Nagi MM, Henry MM, and Riley MT.
of the Sinuses, Diagnosis and Management. Intranasal Photostimulation and
Otolaryngol Head Neck Surg 2001; 129(3): Management of Chronic Rhinosinusitis.
1-32. Otolaryngol Clin North Am. 2005; 38(6):
5. Ahovuo SA, Borisenko OV, and Kovanen 1137-41.
NH. Antibiotics for Acute maxillary Sinuses. 19. Mousten PA, Vinter ND, and Anderson LJ.
Allergy 2008; 58: 176-191. Laser Treatment of Sinusitis in General
6. Shin SH. Chronic Rhino sinusitis: An Practice Assessed by A Double-blind
enhanced Immune Response to Ubiquitous Controlled Study. Ugeskrift for Laeger 2008;
Airborne Fungi. J Allerg Clin. Immunol. 153(32):2232-4.
2004; 114: 1369-1375.
-----[65]-----
EFFECT OF CRANIOCERVICAL FLEXOR TRAINING AND CERVICAL

FLEXOR TRAINING ON SITTING NECK POSTURE IN PATIENTS
WITH CHRONIC NECK PAIN; COMPARATIVE STUDY
Karthikeyan1, Moorthy2
1 PhD, Physiotherapist, DNR, NIMHANS and Bangalore
2 Physiotherapist, AIIMS, Ansari nagar, New delhi
ABSTRACT
BACKGROUND & INTRODUCTION: Poor sitting posture has been implicated in the development and perpetuation
of neck pain symptoms. Cervical spine is surrounded by a complex arrangement of muscles that contribute to control of
the head & neck. The deep cervical short flexor muscle group(longus colli,longus capitis,rectus capitis anterior &
lateralis) is consider to be an important stabilizer of head on neck posture
SUBJECTS AND METHODOLOGY: Sixty Nurses with chronic, non severe neck pain were enrolled in this study. These
subjects were randomly divided into three groups with twenty in each group and named A, B and C. Group A received
craniocervical flexion exercise. Group B received cervico flexion exercise. Group C received both craniocervical flexion
exercise and cervical flexion exercise. Neck pain and disability were measured through Numerical Rating Scale (NRS)
and Neck Disability Index (NDI). The forward head posture were measured from the Digital Photograph method. The
study consisted of exercise session of five weeks with five times in a week.
RESULTS: For all groups, Group A (CCF exercise) , Group B (CFexercise) and Group C (CCFexercise and CFexercise)
the Mean ± SD values were calculated. Groups were compared Using ANOVA (Analysis of variance).The results of the
study suggest that F - values for Craniovertebral angle for Group A , Group B and Group C are 14.54(P<0.001) ,
11.073(P<0.001) and 21.15 (P<0.001)respectively. The F- values for NDI for Group A, Group B and Group C are
63.90(P<0.001) , 53.04(P<0.001) and 67.338(P<0.001). At last the F- values for NRS for Group A, Group B and Group
C are 145.524(P<0.001), 122.06 (P<0.001)and 152.46(P<0.001) respectively .The result further suggests that Group C
is more effective in comparison to the Group A and Group B.
CONCLUSION: This study concludes that combination of both craniocervical flexion exercise and cervical flexion
exercise improves forward head posture and reduce neck pain and disability significantly than the individual
craniocervical flexion exercise and cervical flexion exercise in nurses with chronic nonspecific neck pain.
KEYWORDS: CCF, CF, DNF, FHP, LC, NDI, NRS, SCM
INTRODUCTION flexor exercise on forward head posture & chronic

neck pain.
Cervical spine is surrounded by a
complex arrangement of muscles that contribute AIMS AND OBJECTIVES OF THE
to control of the head & neck. The deep cervical STUDY:
short flexor muscle group(the longuscolli,longus
capitis,rectus capitis anterior & lateralis) is 1) To find the effectiveness of craniocervical
consider to be an important stabilizer of head on flexion exercise as compared to cervical
neck posture2,3. flexion exercise on forward head posture.
Deep cervical flexor muscles act over 2) To find the effectiveness of craniocervical
anterior aspect of upper & middle section of flexion exercise as compared to cervical
cervical spine4. Deep cervical flexor muscles are flexion exercise on chronic neck pain.
small stabilizing muscles located on anterior & 3) To find the combine effect of both
anterior-lateral surface of cervical spine & are craniocervical flexion exercise & cervical
deep to the sternocleidomastoid muscle5.Rectus flexion exercise on forward head posture.
capitis anterior & lateralis course from the atlas to 4) To find the combine effect of both
the basilar & jugular part of occiput craniocervical flexion exercise & cervical
respectively.Longus capitis attaches below to the flexion exercise on chronic neck pain.
transverse process of 3rd to 6th cervical vertebra
& above to basilar part of occiput5. EXPERIMENTAL HYPOTHESIS:
There will be significant differences with
NEED OF STUDY
combination of both craniocervical flexion
The need of present study will be to find exercise and cervical flexion exercise on forward
the individual effect of craniocervical flexor head posture & neck pain and disability as
training & cervical flexor training on forward compared to individual craniocervical exercise
head posture, and to find the combine effect of and cervical flexion exercise.
both craniocervical flexor exercise & cervical
-----[66]-----
METHODOLOGY baseline of 20mm Hg to the final level of 30mm

Hg. Subjects were instructed to gently nod their
Research Approach: Experimental head as though they were saying ‘yes’. Therapist
approach but comparative in nature is chosen for identified the target level that the subject could
conducting the present study. hold steadily for 10 sec. For each target level, the
Study Design: Experimental study contraction duration was increased to 10 sec &
subject trained to perform 10 repetitions. At this
INCLUSION CRITERIA stage, the exercise was progressed to train at the
1) Age: 20-30years. next target level. The exercise is a low-load
2) Forward head posture exercise in nature to more specifically train the
3) History of chronic, non sever neck pain more deep cervical flexors, rather than the neck flexors
than 3 months as a whole, which occurs in a head, lift exercise.
4) Patients who have mild neck pain & GROUP B:
disability scoring 5-15 on Neck Disability Index
5) Poor performance (unable to achieve 24 mm The subjects under this group had been
hg) on clinical test of craniocervical flexion. undergone the endurance-strength training. The
endurance-strength training regimen consisted of
EXCLUSION CRITERIA a progressive resistance exercise program for the
1) People with more severe neck pain (disability neck flexors. The exercise was performed in
scoring more than15 on Neck Disability Index). supine position, with the head supported in a
2) History of fracture or trauma around cervical comfortable resting position. Subjects were
spine instructed to lift up their head so that cervical
3) History of surgery around cervical spine flexion occurred while maintaining a neutral
4) Patient suffering from vertigo and dizziness upper cervical spine position. The subjects slowly
5) Patients having congenital disorders cervical moved the head and neck through as full a range
rib, torticollis, thoracic outlet syndrome of motion as possible without causing discomfort.
6) Any neurological disorder This exercise regimen was a 2-stage program.
The first stage was of 2weeks’ duration
DEPENDENT VARIABLES
and the second was of 3 weeks’ duration for
1) Forward head posture initiating a weight program in previously
2) Neck pain untrained individuals. In stage 1, the subjects
INDEPENENT VARIABLES performed 12 to 15 repetitions with a weight that
they could lift 12 times (12-repetition maximum
1) Craniocervical flexor exercise
[RM]) on the first training session and progressed
2) Cervical flexor exercise
to 15 repetitions and maintained this level for the
PROCEDURE remainder of the 2-week period.
The subjects were randomized into 3 In stage 2, the subjects performed 3sets
exercise groups. of 15 repetitions of the initial 12-RM load once
GROUP A: Craniocervical flexor per day. One minute rest intervals were provided
training intervention. between sets.
GROUP B: Cervical flexor training GROUP C:
intervention. The subjects under this group had been
GROUP C: Both craniocervical flexor gone for both craniocervical flexor and cervical
training and cervical flexor training intervention. flexor intervention with the same protocols as
Postural analysis was performed before above for 5 week.
the intervention, after 2 weeks of intervention and
after 5-week intervention for the three groups.
The exercise regimens were conducted
RESULT
over a 5-week period, 5 times in a week and none
of the exercise sessions were longer than 30 This chapter deals with the results
minutes. The exercises were performed without obtained after the statistical analysis. Statistics
any provocation of neck pain. were performed by using software package SPSS
13 and SIGMASTATE. Results were calculated
GROUP A: using 0.05 level of significance (P<0.05). Groups
The exercise was performed in supine were compared by using ANOVA (Analysis of
position. The sphygmomanometer was used for variance).For ANOVA results were concluded
exercise, the cuff of it placed sub-occipitally to using 0.01 of significance (P<0.01).
monitor the flattening of cervical lordosis that The study consisted of three
occurs with longus colli’s contraction. Subjects experimental groups A, B and C. Each group
were guided by feedback to sequentially reach 5 consisted of 20 subjects:
pressure target in 2 mm Hg increments from a
-----[67]-----
Group A: Craniocervical flexor training FIGURE 1: NRS OF GROUPS A, B AND C

intervention.
GROUP B: Cervical flexor training TABLE 6: MEAN AND SD OF NDI BEFORE
intervention. INTERVENTION, AFTER 2 WEEKS AND
GROUP C: Both craniocervical flexor AFTER 5 WEEKS FOR THE SUBJECTS OF
GROUP A, GROUP B AND GROUP C
training and cervical flexor training intervention.
Group A Group B Group C
Session Mean SD Mean SD Mean SD
TABLE 1: MEAN AND SD OF AGE FOR THE Before Rx 6.9 2.4 5.9 1.43 7.3 2.36
SUBJECTS OF GROUP A, GROUP B AND After 2 weeks 4.05 1.05 3.9 1.25 4.95 1.84
GROUP C After 5 weeks 1.45 0.826 1.35 1.04 1.80 0.696
GROUP A GROUP B GROUP C

Mean±SD Mean±SD Mean±SD TABLE 7: COMPARISON OF MEAN VALUES
AGE 21.05O±3.236 20.000±0.000 21.150±2.943 OF NDI OF GROUP A, GROUP B & GROUP C
AT INTERVALS PRE- 2 WEEK, 2 WEEK-
TABLE 2: MEAN AND SD OF 5WEEK, PRE- 5 WEEK
CRANIOVERTEBRAL ANGLES BEFORE Group A Group B Group C
INTERVENTION, AFTER 2 WEEKS AND NDI t p t p t p
AFTER 5 WEEKS FOR THE SUBJECTS OF Pre- 2 week 8.14 <0.05 8.34 <0.05 7.85 <0.05
GROUP A, GROUP B AND GROUP C 2 week-5week 17.08 <0.05 9.57 <0.05 9.87 <0.05
Pre- 5 week 18.16 <0.05 10.06 <0.05 12.27 <0.05
Group A Group B Group C
Session Mean SD Mean SD Mean SD
Before Rx 46.75 4.43 43.9 5.14 46.95 4.43
After 2 weeks 49.5 2.83 48.4 5.3 51.6 4.83
After 5 weeks 52.85 2.84 52 5.14 56.25 4.78
TABLE 3: COMPARISON OF MEAN VALUES

OF CARNIOVERTEBRAL ANGLE OF GROUP
A, GROUP B & GROUP C AT INTERVALS PRE-
2 WEEK, 2 WEEK-5WEEK, PRE- 5 WEEK
Carnivertebral Group A Group B Group C
angle t- P t p t p
Pre- 2 week 9.28 <0.05 9.52 <0.05 8.47 <0.05
2 week-5week 10.63 <0.05 11.103 <0.05 11.16 <0.05 FIGURE 2: NDI OF GROUP A, B AND C
Pre- 5 week 18.16 <0.05 17.926 <0.05 18.21 <0.05
TABLE 8: COMPARISON OF F-VALUE FOR
TABLE 4: MEAN AND SD OF NRS BEFORE CRANIOVERTEBRAL ANGELE, NRS, NDI
INTERVENTION, AFTER 2 WEEKS AND BETWEEN GROUP A, GROUP B AND GROUP
AFTER 5 WEEKS OF INTERVENTION OF C
GROUP A, GROUP B AND GROUP C Group A Group B Group C
Variable F P F P F P
Session Group A Group B Group C
Mean SD Mean SD Mean SD Craniovertebral
14.546 0.0067 11.073 0.0073 21.155 0.0064
angle
Before Rx 3.75 0.44 3 0.47 3.9 0.308
NRS 145.524 0.0053 122.03 0.0071 152.465 0.0043
After 2 weeks 2.3 0.57 2.1 0.5 2 0.48
NDI 63.903 0.0081 32.208 0.0082 67.338 0.0077
After 5 weeks 0.55 0.605 0.4 0.5 0.80 0.41
TABLE 5: COMPARISON OF MEAN VALUES DISCUSSION

OF NRS OF GROUP A, GROUP B & GROUP C
AT INTERVALS PRE- 2 WEEK, 2 WEEK- The present study was performed on 60
5WEEK, PRE- 5 WEEK subjects of age group 20-40 years to know the
Group A Group B Group C individual effectiveness of craniocervical flexion
NRI t p t p t p exercise, cervical flexion exercise and combine
Pre- 2 week 12.70 <0.05 12.704 <0.05 12.70 <0.05
2 week-5week 16.05 <0.05 14.24 <0.05 14.24 <0.05
effect of both craniocervical exercise and cervical
Pre- 5 week 29.0 <0.05 18.006 <0.05 20.56 <0.05 flexion exercise on forward head posture, pain and
disability in subjects with chronic nonspecific
neck pain.
Subjects were divided into 3 groups with
20subjects in each group. Subjects in Group A
were treated with Craniocervical flexion exercise.
Subjects with Group B were treated with cervical
flexion exercise and subjects in group C were
treated with both craniocervical flexion exercise
and cervical flexion exercise.
Results showed that combination of both
craniocervical flexion exercise and cervical
-----[68]-----
flexion exercises is highly effective in improving with chronic cervical origin headache and forward
forward head posture, pain and disability in resting head posture.
Nurses with neck pain than the individual In this study CCF exercise, CFT exercise
craniocervical flexion exercise and cervical and combination of both CCF exercise and CF
flexion exercise with respective F-values exercise are used as the intervention. Previous
11.073(P=0.0064),152.46(P=0.0043),88.03(0.00 research proved that CCF exercise and CF
77) in Group C. exercise individually effective in reducing chronic
Group A which underwent CCFE also neck pain by improving performance of DNF
showed highly significant improvement in FHP, muscles. Previous study showed that anterior head
decrease pain and decrease disability than Group weight bearing reduce the forward head posture,
B which undergone CFE with F value of which is shown in this study also in Group B. CF
craniovertebral angle of Group A and Group B exercise is effective in reducing myoelectrical
14.546(P=0.0053) & 11.073(P=0.0071), F value manifestation of superficial cervical flexor muscle
of NRS of Group A and Group B fatigue as well as increasing cervical flexion
14.524(P=0.0081) &122.06(P=0.0082) and F strength in a group of patients with chronic non
value of NDI 63.90 & 32.208 respectively. sever neck pain5.
Result shows that Group C showed better In this study we also found that CCF
improvement than the Group A and Group B. exercise is significant than the CF exercise to
Thus result support our experimental hypothesis- improve forward head posture and to reduce neck
There will be significant differences with pain and disability. Previous study showed the
combination of both craniocervical flexion effect of CCF exercise and CF exercise
exercise and cervical flexion exercise on forward individually and found CCF exercise better than
head posture & neck pain and disability as the CF exercise to reduce neck pain and disability.
compared to individual craniocervical exercise But none of the study has been shown the combine
and cervical flexion exercise. effect of both CCF and CF exercises on neck pain
Group C showed significant reduction in and forward head posture. This study used the
pain on NRS with F value 152.465 compared to combination of both CCF and CF exercise and
Group A and Group B which having F showed that combination of both exercises is
values145.524, 122.03 for NRS respectively. more effective than the individual CCF exercise
There is significant reduction in pain intensity but and CF exercise and also showed that CCF
Group C showed greater reduction than the Group exercise is effective than the CF exercise to
A and Group B. In Group C subjects underwent improve FHP and to reduce the neck pain and
both CCF exercise and CF exercise, in which CF disability.
exercise concentrated on both deep and superficial Combination of both CCF exercise and
neck muscles and CCF exercise concentrate on CF exercise strengthen the DCF mainly and also
DCF muscles. superficial neck flexors, improved the endurance
In this study, CCF exercise was done by of DCF, retrained the DCF.CCF exercise mainly
using sphygmomanometer as feedback for strengthen the DCF muscles only and CF exercise
retraining the DCF muscles and it showed improve the endurance of deep and superficial
significant improvement in the performance of the neck muscles. Due to this reason combination of
DCF muscle, thus this study is supported by the both exercise showed the highest significant
above researches for the use of CCF action for improvement in FHP and neck pain and disability
retraining the DCF muscles. compared to the individual CCF exercise and CF
Group A, Group B and Group C showed exercise.
significant improvement in FHP.F values for According to the result of this study if the
craniovertebral angle of Group A, Group B and combination of both CCF exercise and CF
Group C are 14.546, 11.073, 21.155 respectively. exercise is used in chronic nonspecific neck pain
This showed that subjects in group C who patient then it will be so beneficial to improve
underwent combination of both CCF exercise and FHP and reduce neck pain and disability.
CF exercise showed significant improvement in
FHP compared to the Group A and Group B. CONCLUSION
Patients with chronic neck pain may tend
to develop an increased cervical lordotic posture The study concluded that both combine
associated with a forward head posture, and had CCF and CF exercises are better in improving
less cervical backward bending. A sustained forward head posture and reducing neck pain and
forward flexion posture of spine has been disability in Nurses having neck pain than the
associated with increased cervical compressive individual CCFE and CFE .The Craniocervical
loading and creep response in the connective flexion exercise is more effective than Cervical
tissue. Poor isometric performance of the cervical flexion exercises.
short flexor muscle has been observed in females
-----[69]-----
REFERENCES syndromes.in grant

RE(Ed),Nweyork:Churchill
1. Lee E,Olsen, Millar AL et al.Reliability of a livingstone,physical therapy.1988;17:153-
clinical test for deep cervical flexor 166.
endurance. journal of manipulative physical 4. Basmajian JV.Muscle
therapy.2006;29(2):134-138. Alive,Baltimore:Williams & wilkins
2. Williams P & Warwick R (1980): Grays Co,1979:p.175-293.
Anatomy 36th ed Edinburgh Churchill 5. Mauoux Benhamou MA. Longus colli has a
livingstone. postural function on cervical curvature.Surg
3. Jands V.Muscle and cervicogenic pain Radiology Anat.1994; 16:367-371
-----[70]-----
EFFECT OF BALANCE EXERCISES ON BALANCE, PAIN AND

FUNCTIONAL PERFORMANCE IN OSTEOARTHRITIS KNEE
Anjali Goel1, Shagun Agrawal2, Meenakshi Verma3
1. Research student, Institute of applied medicines and research, Ghaziabad
2. Research Guide, M.P.T Sports, Head of Department, Institute of applied medicines and research,
Ghaziabad
3. Research Co- Guide, M.P.T Neurology, Assistant Professor, Institute of applied medicines and research,
Ghaziabad
ABSTRACT
BACKGROUND AND PURPOSE: Traditionally, rehabilitation programs Improves muscle strength and proprioception
which may reduce the progression of knee OA. The purpose of the study to evaluate the effect of balance exercises in
improving balance, functional performances and decreasing pain in osteoarthritis knee.
METHODS: 30 patients meeting the inclusion criteria was randomly divided into groups. Subjects received one hour
individualized training sessions. Group A received quads. Sets, SLR, Flexion-extension and 20 mins short wave
diathermy. Exercises are performed 30 repetitions of each exercise (3 sets of 10 repetitions). Group B received
strengthening exercises as well as balance exercises which includes Side stepping, Front and backward, crossover steps
during forward ambulation, Retrowalking etc. Exercises were performed 5 days in a week for 4 weeks. Step Test,
Functional Reach Test, WOMAC Questionnaire, Visual Analogue Scale were the outcome measure and their scores for
all groups were taken prior and after the training.
RESULTS: Pre test and post test outcome measures (VAS, WOMAC, Step test and FRT) of two independent groups were
compared by repeated measures analysis of variance (RM ANOVA) using general linear models (GLM) and the
significance of mean difference within and between the groups was done by Newman-Keuls post hoc test. And the results
revealed that post intervention scores were highly significant (p 0.05) in group B and performed better than group A.
CONCLUSION: In conclusion, Study found both the balance exercises effective in improving balance, functional
performance and decreasing pain in osteoarthritis knee but Group B was found to be significantly more effective than
Group A.
KEYWORDS: Osteoarthritis, Balance, step test, WOMAC, Functional reach test, visual analogue scale
INTRODUCTION within the base of support in situations when

balance is disturbed18,30,45
Knee osteoarthritis (OA) is one of the Hassan B, Mockett S et al in 2001,
most prevalent musculoskeletal complaints Hinman R, Bennell K et al in 2002, Jadelis K,
worldwide, affecting 30–40% of the population Miller M et al in 2001 and K.L. Bennell,
by the age of 65 yr28,50. Osteoarthritis is the R.S.Hinman in 2004 have demonstrated a
common form of arthritis, with an associated risk relationship between the severity of knee pain and
of mobility and disability12. The knee is the most balance whereby greater knee pain is associated
frequently involved joint of the lower limb in OA. with poorer balance30,33,45. The term
The prevalence of knee OA increases with age proprioception encompasses both the sensations
because aged cartilage is more vulnerable to of the joint movement (kinesthesia) and the joint
physiologic load, and the resulting load across the position sense (JPS). Both components of lower
articular surface changes mechanical, neural and limb proprioception seem integral for the
surrounding muscles of the knee18. regulation of balance and postural control48.
In people at risk, local mechanical Lack of proprioceptive sensation causes
factors such as misalignment, muscle weakness, altered gait and unphysiological joint loading;
or alterations in the structural integrity of the joint slowly progressive joint degeneration may
environment (such as meniscal damage) facilitate follow10. Improvement in muscle strength and
the progression of the disease12. Knee pain could proprioception gained from exercise may reduce
influence balance control via effects on the progression of knee OA16. Purpose of the
proprioceptive input, central processing of study is to evaluate the effect of balance exercises
information and efferent output to activate in improving balance, functional performances
appropriate limb and trunk muscles6,30,33,50. and decreasing pain in osteoarthritis knee.
Control of balance is dependent upon sensory Four scale are used to assess the
input from the vestibular, visual and outcomes of both interventions. They are Step
somatosensory systems. Central processing of this Test, Functional Reach Test, WOMAC
information results in coordinated neuromuscular Questionnaire, Visual Analogue Scale, These
responses that ensure the centre of mass remains
-----[71]-----
scales have good reliability and validity. These 4)Multiple change in direction during
scales have been selected for study because walking on physiotherapist command
1.They are very simple to administer 5)Tilt board balance training
2.They are quick and practical. 6)Sitting down and standing up from
3.They are easy to be conducted in high chair
Indian clinical setting 7)Sitting down and standing up form low
chair.
METHODS Exercises were performed 5 days in a
week for 4 weeks.
Selection and description of participation: STATISTICS
Total 30 patients out of 35 patients Data were summarized as Mean ± SD.
meeting the inclusion criteria were selected. 30 Demographic continuous variable (age) of two
subjects were selected on the basis of inclusion independent groups (Group A: Control, Group B:
criteria from Modern physiotherapy centre and Intervention) were compared by Student’s t test
Shanti Gopal Hospital, Ghaziabad. while discrete data (sex) were analyzed with
To participate subjects had to meet the Fisher’s exact test. The pre test and post test
inclusion criteria: (i) Primary osteoarthritis on outcome measures (VAS, WOMAC, Step test and
bilateral knee joint of age > 50 yrs. (ii) Knee pain FRT) of two independent groups were compared
on most of the previous month. [Average pain > by repeated measures analysis of variance (RM
3 cm on a 10-cm Visual Analogue Scale (VAS)] ANOVA) using general linear models (GLM) and
(iii) Experience pain and / or difficulty when the significance of mean difference within and
getting up from sitting or climbing stairs. (iv) between the groups was done by Newman-Keuls
Demonstrated osteophytes on X-RAY. [Grade II post hoc test. A two-tailed (α=2) probability
or greater kellgren and Lawrence grading system]. p<0.05 was considered statistically significant.
Exclusion criteria for the patients were- All analyses were performed on SPSS (version
(i) Reported a cold or ear infection within 15.0).
previous month. (ii)History of dizzy spells,
fainting episodes. (iii) Light headaches. RESULT
(iv)Secondary osteoarthritis. (v) Past history of
lower limb joint replacement. (vi) Neurological Demographic characteristics-
disorder.
All the two groups were matched in
Procedure terms of age and gender.
30 patients meeting the inclusion criteria Sex
was randomly divided into two groups (Group A
The sex proportions (M/F) of two groups
and B) each consisting of 15 subjects.
(Group A: Control and Group B: Intervention)
Group A: Received strengthening
were shown graphically in figure 1. In both the
exercises and SWD.
groups, the proportions of females were higher
Group B: Received strengthening and
than males, but their proportions did not differed
balance exercises.
between the two groups i.e. found to be
Before starting the exercises, patients
statistically the same (M/F: 5/10 vs. 4/11,
were given hot pack for 20 min.
p=1.0000). In other words, the subjects of two
Group (A) protocol consists of
groups were sex matched.
strengthening exercises which includes [46]:
Sex
1)Quads Sets.
15
2)SLR. Fisher's exact test: p=1.0000 Male
Number of subjects
3)Knee flexion, Extension. 11 Female

10
Exercises are performed 30 repetitions of 10
each exercise (3 sets of 10 repetitions).
5
Patients were also given SWD for 20 min 5 4
by placing malleable electrodes around the
affected knee. 0
Group (B) protocol consists of Group A Group B
strengthening exercises as well as balance Groups
exercises which includes [15, 32]:
1)Side stepping FIGURE 1: FREQUENCY DISTRIBUTION OF
SEX IN TWO GROUPS
2)Front and backward crossover steps
during forward ambulation
3)Retrowalking
-----[72]-----
Age significantly at post test (3.40 ± 0.99 vs. 1.67 ±

The age of two groups were A ranged 0.90, p=0.0001). In other words, VAS scores were
from 50-70 yrs with mean (± SD) 58.40 ± 5.82 yrs comparable at baseline (pre test) and at post test
while of Group B it ranged from 50-69 yrs with (at the end of 4 wk or after 4 wks of treatment),
mean (± SD) 58.87 ± 5.80 yrs. The mean age of the VAS decreased significantly more in Group B
Group A and Group B did not differed than group A.
VAS
significantly (p>0.05) i.e. found to be statistically
the same (58.40 ± 5.82 vs. 58.87 ± 5.80, 10.0
Group A
ns
p=0.8275). In other words, the subjects of two 7.5
Group B
Mean  SD
groups were age matched.
5.0
Age (yrs)
**
2.5
75
ns
0.0
Mean  SD
Pre test Post test

50
Periods
FIGURE 4: BAR GRAPH SHOWS MEAN (± SD)

25
VAS SCORES OF TWO GROUPS AT PRE TEST
AND POST TEST AND ALSO COMPARES THE
0 SCORES BETWEEN THE GROUPS (WITHIN
PERIODS). NS- P>0.05, **- P<0.001
Group A Group B
Groups WOMAC
FIGURE 2: BAR GRAPH SHOWS MEAN (± SD) Comparing (figure 5) the mean
AGE OF TWO GROUPS AND ALSO WOMAC scores within the groups, the WOMAC
COMPARES THE AGE BETWEEN THE scores decreased significantly (p<0.001) in Group
GROUPS A (58.40 ± 3.14 vs. 34.20 ± 1.42, p=0.0001) and
Group B (59.67 ± 3.60 vs. 25.67 ± 2.02,
Outcome measures p=0.0002) at post test as compared to pre test.
VAS WOMAC
Comparing (figure 3) the mean VAS 75

Pre test
scores within the groups (i.e. between periods or Post test
Mean  SD
pre test vs. post test), the VAS scores decreased 50

significantly (p<0.001) in Group A (7.93 ± 0.70 **
vs. 3.40 ± 0.99, p=0.0001) and Group B (7.53 ± 25
**
0.74 vs. 1.67 ± 0.90, p=0.0001) at post test as

compared to pre test. 0
VAS
Group A Group B
10.0 Groups
Pre test
Post test
7.5
Mean  SD
5.0 **
WOMAC SCORES OF TWO GROUPS AT PRE
**
2.5 TEST AND POST TEST AND ALSO COMPARES
THE SCORES BETWEEN THE PERIODS
0.0
(WITHIN GROUPS). **- P<0.001
Group A Group B
Groups
Similarly, comparing (figure 6) the mean
WOMAC scores between the groups, the
FIGURE 3: BAR GRAPH SHOWS MEAN (± SD) WOMAC scores did not differed between the two
VAS SCORES OF TWO GROUPS AT PRE TEST groups at pre test (58.40 ± 3.14 vs. 59.67 ± 3.60,
AND POST TEST AND ALSO COMPARES THE p=0.2028) while differed significantly at post test
SCORES BETWEEN THE PERIODS (WITHIN (34.20 ± 1.42 vs. 25.67 ± 2.02, p=0.0001). In
GROUPS). **- P<0.001 other words, WOMAC scores were comparable at
baseline (pre test) and at post test (at the end of 4
Similarly, comparing (figure 4) the mean wk or after 4 wks of treatment), the WOMAC
VAS scores between the groups (Group A vs. decreased significantly more in Group B than
Group B), the VAS scores did not differed group A.
between the two groups at pre test (7.93 ± 0.70 vs.
7.53 ± 0.74, p=0.1982) while differed
-----[73]-----
WOMAC Step test
75 20
Group A Group A
ns
Group B Group B
Mean  SD
**
Mean  SD
50
10 ns
**
25
0 0
Pre test Post test Pre test Post test
Periods Periods

WOMAC SCORES OF TWO GROUPS AT PRE FIGURE 8: BAR GRAPH SHOWS MEAN (± SD)
TEST AND POST TEST AND ALSO COMPARES STEP TEST SCORES OF TWO GROUPS AT
THE SCORES BETWEEN THE GROUPS PRE TEST AND POST TEST AND ALSO
(WITHIN PERIODS). NS- P>0.05, **- P<0.001 COMPARES THE SCORES BETWEEN THE
GROUPS (WITHIN PERIODS). NS- P>0.05, **-
Step test P<0.001
Comparing (figure 7) the mean step test
scores within the groups, the step test scores FRT
increased significantly (p<0.001) in Group A Comparing (figure 9) the mean FRT scores within
(7.20 ± 0.86 vs. 10.33 ± 0.98, p=0.0001) and the groups, the FRT scores increased significantly
Group B (7.67 ± 1.05 vs. 13.07 ± 1.22, p=0.0001) (p<0.001) in Group A (4.53 ± 0.86 vs. 6.91 ± 1.03,
at post test as compared to pre test p=0.0001) and Group B (4.84 ± 0.87 vs. 7.56 ±
Step test 0.62, p=0.0001) at post test as compared to pre
20 test.
Pre test FRT
Post test
Mean  SD
** 10.0
Pre test
** **
10 ** Post test
Mean  SD
7.5
5.0
0 2.5
Group A Group B
Periods 0.0
Group A Group B
FIGURE 7: BAR GRAPH SHOWS MEAN (± SD) Periods
STEP TEST SCORES OF TWO GROUPS AT
PRE TEST AND POST TEST AND ALSO FIGURE 9: BAR GRAPH SHOWS MEAN (± SD)
COMPARES THE SCORES BETWEEN THE FRT SCORES OF TWO GROUPS AT PRE TEST
PERIODS (WITHIN GROUPS). **- P<0.001 AND POST TEST AND ALSO COMPARES THE
SCORES BETWEEN THE PERIODS (WITHIN
Similarly, comparing (figure 8) the mean GROUPS). **- P<0.001
step test scores between the groups, the step test
scores did not differed between the two groups at Similarly, comparing (figure 10) the
pre test (7.20 ± 0.86 vs. 7.67 ± 1.05, p=0.2226) mean FRT scores between the groups, the FRT
while differed significantly at post test (10.33 ± scores did not differed between the two groups at
0.98 vs. 13.07 ± 1.22, p=0.0001). In other words, pre test (4.53 ± 0.86 vs. 4.84 ± 0.87, p=0.3257)
step test scores were comparable at baseline (pre while differed significantly at post test (6.91 ±
test) and at post test (at the end of 4 wk or after 4 1.03 vs. 7.56 ± 0.62, p=0.0411). In other words,
wks of treatment), the step test increased FRT scores were comparable at baseline (pre test)
significantly more in Group B than group A. and at post test (at the end of 4 wk or after 4 wks
of treatment), the FRT increased significantly
more in Group B than group A.
-----[74]-----
FRT importance of these exercises in knee OA. Robert

10.0 Topp et al, exercises can reduce pain and increase
Group A
* Group B
the perceived and actual functional abilities of OA
7.5
patients53.
Mean  SD
ns
5.0 Hu and Woollacott suggested that
general exercise programs are less effective than
2.5 programs that target a specific system (e.g. visual,
0.0
vestibular, somatosensory) that functions to
maintain balance. Ufuk sekir et al concludes that
Pre test Post test
Periods short term proprioceptive/ balance training
improves balance and proprioception in older OA
FIGURE 10: BAR GRAPH SHOWS MEAN (± SD) patients59.
FRT SCORES OF TWO GROUPS AT PRE TEST VAS is used in this study for pain
AND POST TEST AND ALSO COMPARES THE
assessment. VAS is regarded as a valid and
SCORES BETWEEN THE GROUPS (WITHIN
PERIODS). NS- P>0.05, *- P<0.05 reliable tool for pain measurement49.
WOMAC questionnaire is commonly
used in evaluating physical function and is often
DISCUSSION used in knee osteoarthritis. Evcik et al evaluated
the functional capacity and pain by using VAS
This study consisted of two groups- and WOMAC in patients with knee OA. There is
group A (control) and group B (Experimental). moderate relationship between the WOMAC
The subjects of group A were given Strengthening scores and pain levels59.
exercises and SWD and group B were given Step test is used for balance assessment
Strengthening exercises as well as balance and it is an easy to use and well known reliability
exercises. The main findings were that both the and validity. Step test is a functional and dynamic
group shown significant improvement in VAS, test of standing balance6.
WOMAC, Step test and FRT.
Demirhan Diracoglu, Resa Aydin et al in FUTURE RESEARCH
2005 studied the effect of kinesthesia and balance
exercises in knee osteoarthritis. They measure Future research could be done by
change in functional status, isokinetic muscle comparing various balance exercise in different
strength and proprioceptive sense accuracy. grades of osteoarthritis. Assessment of static
Significant changes were detected in the balance in knee OA are also need consideration in
kinesthesia group. They conclude that addition of future studies.
kinesthesia and balance exercises that help
neuromuscular restoration to standard RELEVANCE TO CLINICAL
strengthening exercises provides dynamic muscle PRACTICES
strength increase with significant recoveries in the
This study shows that patient with knee
functional status of the patients15.
OA shows improvement in balance and functional
There is also improvement in group A
performance and decrease pain by performing
(control) that may be because of previous study by
strengthening and balance exercises as compare to
Kristen Jadelis, Michael E. Miller et al in 2001
those who are performing only strengthening
concluded that strength also appears to play a
exercises. Thus, balance exercises should be
significant role in maintaining balance in an older,
incorporated along with strengthening exercises
osteoarthritic population. They showed that
in Knee OA patients to improve balance,
quadriceps weakness in older adults with knee OA
functional performance and decreasing pain.
plays an important role in physical function33.
Conclusion
R. S. Hinamn, K.L. Bennell et al in 2002
Study found both the balance exercises
showed that deficits in lower limb proprioception
effective in improving balance, functional
and muscle strength are associated with knee OA
performance and decreasing pain in osteoarthritis
and thus may be postulated as a cause of impaired
knee but Group B was found to be significantly
balance. Pain associated with the osteoarthritis
more effective than Group A. The VAS,
knee may play a role in balance impairments50.
WOMAC, step test and FRT improved 1.36, 1.38,
Volga Bayracki Tunay et al, given
1.62 and 1.07 times more respectively in patients
strengthening exercises and proprioceptive
those who received the Group B than those who
training in order to improve proprioceptive sense
received the Group A.
which is part of balance during functional
activities. They show improvement in pain and
proprioception59. REFERENCES
Strengthening exercises were given
because of previous study that shows the 1. Adegoke and Gbeminiyi: efficiacy of ice
-----[75]-----
and shortwave diathermy in the N Engl J Med, 354 Vol. 841-848, 2006.
management of osteoarthritis of knee- a 15. Demirhan diracoglu, Resa Aydin et al:
preliminary report. African journal of Effects of kinesthesia and balance exercises
biomedical reseach, vol 7, No. 2, 59-63, may in knee osteoarthritis. Journal of clinical
2004. Rheumatology, Vol. 11, 303-310, December
2. Ambika Damodaran, Surya Bhan et al: 2005.
Balance assessment in patient with knee 16. E. Roddy, W. Zhang et al: Evidence based
osteoarthritis. Archives of Physical recommendations for the role of exercise in
medicine and rehabilitation. Vol. 89, p e21, the management of osteoarthritis of the hip
November 2008. or knee- the MOVE consensus.
3. Andrew A., David T. Felson et al: The Rheumatology, Vol. 44, No.1, 67-73,
condition of specific medical conditions on September 2007.
the functional limitations of elderly in the 17. F. Angst, A Aeschilmann et al:
Framingham study. American journal of Responsiveness of the WOMAC
public health, vol 84, No.3, 351-358, 1994. osteoarthritis index as compared with the
4. Angela K. Lange, Benedicte Vanwansele et SF-36 in patients with osteoarthritis of the
al: Strength training for osteoarthritis of the legs undergoing a comprehensive
knee: A systemic review. Arthritis & rehabilitation intervention. Ann Rheum dis,
Rheumatism, vol 59, No.10, 1488-1494, 834-840, 2001.
October 15, 2008. 18. Farshid Mohammadi, Shohreh Taghizadesh
5. Anne l Harrison: the influence of pathology, et al: Proprioception, dynamic balance, and
pain, balance, and self-efficacy on function maximal quadriceps strength in females
in women with osteoarthritis of the knee. with knee osteoarthritis and normal control
Physical Therapy, Vol 84, No.9, 822-831, subjects. International Journal of Rheunatic
September 2004. disease, 39-44, 2008.
6. B S Hassan, S A Doherty et al: Effect of pain 19. Frederick Wolfe and Nancy E. lane: The
reduction on postural sway, proprioception, longterm outcome of osteoarthritis: rates
and quadriceps strength in subjects with and predictors of joint space narrowing in
knee osteoarthritis. Ann Rheum Dis, 61, symptomatic patients with knee
422-428, 2002. osteoarthritis. J Rheumatol, 139-146, 2002.
7. Bellamy N, Buchanan WW et al: Validation 20. G. Kelly Fitzgerald, sara R. Piva et al:
study of WOMAC: a health status quadriceps activation failure as a moderator
instrument for measuring clinically of the relationship between quadriceps
important patient relevant outcomes to strength and physical function in individual
antirheumatic drug therapy in patients with with knee osteoarthritis. Arthritis care and
osteoarthritis of the hip or knee. J Research Vol, 51, 40-48, 15 february 2004.
Rheumatol, 1833-1840, December 15, 1988. 21. Gail D. deyle, Nancy E. Henderson et al:
8. Bronwen A. Hewit, Kathryn M. Refshague Effectiveness of manual physical therapy
et al: kinesthesia at the knee: The effect of and exercise in osteoarthritis of the knee.
osteoarthritis and bandage application. Annals of Internal medicine, Vol. 132, 173-
Arthritis & Rheumatism, vol. 47, No.5, 479- 181, 1 February 2000.
483, October 2002. 22. Gail D. Deyle, Stephen C Allison et al:
9. Charles Slemenda,, Kenneth D. Brandt et al: Physical therapy treatment effectiveness for
Quadriceps Weakness and Osteoarthritis of osteoarthritis of the knee: A Randomized
the Knee.Americal college of physician, comparison of supervised clinical exercise
Vol. 127, 97-104, 15 july 1997. and manual therapy procedures versus a
10. D. S. Barrett, A.G. Cobb et al: Joint home exercise program. Physical Therapy,
proprioception in normal osteoarthritic, and vol. 85, 1301-1317, December 2005.
replaced knees. J bone joint surg/br, Vol. 73, 23. H.T. Weiler, G. Pap and F. Awiszus: The
53-56, January 1991. role of joint afferents in sensory processing
11. David J Hunter, David T Felson: in osteoarthritis knees, Rheumatology, 850-
osteoarthritis. BMJ,Vol. 332, 639-642, 856, 2000.
March 18, 2006. 24. Henrik Rogind, Birgitte Bibow-Nielsen B et
12. David T. Felson, et al: Osteoarthritis: New al: The effects of a physical training
sight. Part 1: The disease and its risk program on patients with osteoarthritis of
factors.Ann intern Med, 1-29, 2000. the knees. Arch Phys Med Rehabil, Vol, 79,
13. D. T. Felson et al: Osteophyte and 1421-1427, November 1998.
progression of knee osteoarthritis. 25. Ingemar F Petresson, Torsten Boegard:
Rheumatology, Vol.44, 100-104, 2004. Radiographic osteoarthritis of the knee
14. David T. Felson: Osteoarthritis of the knee. classified by the Ahlback and Kellgren &
-----[76]-----
Lawrence system for the tibiofemoral joint 38. M E Van Baar , J Dekker et al: Effectiveness
in people aged 35-54 years with chronic of exercise in patients with osteoarthritis of
knee pain. Ann Rheum dis, 493-496, 1997. hip or knee: Nine months follow up. Ann
26. J. H. Kellgren and J. S. Lawrence: Rheum Dis, 1123-1130, 2001.
Radiological assessment of osteoarthrosis. 39. M. V. Hurley and D.L. Scott: Improvements
Ann Rheum Dis, 494-502, 1957. in quadriceps sensorimotor function and
27. Janie L. Astephen, Kevin J. Deluzio et al: disability of patients with knee osteoarthritis
Biomechanical changes at the hip, knee, and following a clinically practicable exercise
ankle joints during gait ase associated with regime. British journal of Rheunatology,
oateoarthritis severity. JOR, 322-341, 2008. 1181-1187, 1998.
28. J L Van Saase, L K van Romunde, A Cats et 40. M. Van Der Esch, M. Steultjens et al: joint
al: Epidemiology of osteoarthritis: proprioception, muscle strength, and
Zoetermeer survey. Comparison of functional ability in patients with
radiological osteoarthritis in a dutch osteoarthritis of the knee. Arthritis &
population with that in 10 other population. Rheumatism, Vol. 57, No. 5, 787-793, 2007.
Ann Rheum Dis, 271-280, 1989. 41. Margriet E. Van Baar, Willem J. J.
29. Jyoti Mehta, K P Mulgaonkar: Effect of assendelft et al: effectiveness of exercise
laterally raised footwear on bilateral medial therapy in patients with osteoarthritis of the
compartment knee osteoarthritis and its hip or knee. Arthritis & Rheumatism, vol.
biomechanical analysis- a comparative 42, No. 7, 1361-1369, 7 July, 1999.
study. The Indian journal of occupational 42. Md. Moniuzzaman khan, AKM. Salek et al:
therapy, Vol. XXXVI: No. 3, December Physical management of patients with
2004- march 2005. osteoarthritis of knee. BSMMU J 95-98,
30. K. L. Bennell and R. S. Hinman: Effect of 2009.
experimentally induced knee pain on 43. Mei-Hwa Jan, Jiu-Jeng Lin: Investigation of
standing balance in healthy older clinical effects of high and low resistance
individuals. Rheumatology Vol.44 No. training for patients with knee osteoarthritis:
3,378-381, November 30, 2004. A randomized controlled trial. Physical
31. Kim L. Bennell, Rana S. Hinamn et al: therapy, Vol. 88, No. 4, 427-436, April
Relationship of knee joint proprioception to 2008.
pain and disability in individuals with knee 44. Michael V Hurley, David L Scott, Joanne
osteoarthritis. Joural of orthopaedic Rees et al: Sensorimotor changes and
research, 792-797, 2003. functional performance in patients with knee
32. Kristen A. Scopaz, Sara R, Piva et al: The osteoarthritis. Ann Rheum Dis., 641-648,
effect of baseline quadriceps activation on 1997.
changes in quadriceps strength after exercise 45. Michael V. Hurley, Joanne Rees:
therapy in subjects with knee osteoarthritis. Quadriceps function, Proprioceptive acuity
Arthritis Rheum, 951-957, July 15, 2009. and functional performance in healthy
33. Kristen jadelis, Michael E. Miller et al: young, middle-aged and elderly subjects.
Strength, balnce, and the modifying effects Age and Ageing, 55-62, 1998.
of obesity and knee pain: Results from the 46. N. Shakoor, S. Furmanov et al: Pain and its
observational arthritis study in seniors relationship with muscle strength and
(OASIS). JAGS, 884-891, 2001. proprioception in knee OA: results of an 8
34. Leena Sharma: The role of proprioceptive week home exercise pilot study. J
deficits, ligamentous laxity, and Musculoskeletal Neuronal Interact, 35-42,
malalignment in development and 2008.
progression of knee osteoarthritis. 47. Nisha J. Manek and Nancy E. lane:
Rheumatology, 2004. osteoarthritis: Current concept in diagnosis
35. Leena Sharma, Dorothy D. Dunlop et al: and management.American academy of
Quadriceps strength and osteoarthritis family physician, March 15, 2000.
progression in malaligned and lax knees. 48. Nursen ozdemir, Sevgi Sevi Subasi et al:
Annals of internal medicine, 613-620, 2003. The effects of pilates exercise training on
36. Lisa M. Koralewicz and Gerard A. Engh: knee proprioception – A randomized
Comparison of proprioception in arthritic controlled trial. MAYIS, 71-79, 2009.
and age matched normal knees. JBJS, 1582- 49. Polly E. Bijur, Wendy silver et al:
1588, 2000. Reliability of the visual analogue scale for
37. M. P. M. Steultjens, J. Dekker et al: Range measurement of acute pain. Academic
of joint motion and disability in patients emergency medicine, Vol. 8, No.12,
with osteoarthritis of the knee or hip. December 2001.
Rheumatology, 955-961, 2000. 50. R.S. Hinman, K.L. Bennell et al: Balance
-----[77]-----
impairments in individuals with osteoarthritis. J Musculoskelet Neuronal

symptomatic knee osteoarthritis: a Interact, 376-378, 2006.
comparison with matched controls using 56. Sara Mcconnell, Pamela Kolopack et al: The
clinical tests. Rheumatology, 1388-1394, western Ontario and mcmaster universities
2002. osteoarthritis index (WOMAC): a review of
51. Robin Poole: An introduction to the its utility and measurement properties.
pathophysiology of osteoarthritis. Frontiers Arthritis care & research, 453-461, 2001.
in Bioscience 4, 662-670, October 15, 1999. 57. Shin Hung Chuang, Mao-Hsiung Huang et
52. Rebecca Grainger and Flavia M Cicuttini: al: effect of knee sleeve on static and
Medical management of osteoarthritis of the dynamic balance in patients with knee
knee nad hip joints. MJA, 232-236, 2004. osteoarthritis. Kaohsiung J Med Sci, Vol.
53. Robert Topp, Sandra Woolley et al: The 23, 405-411, 2007.
effect of dynamic versus isometric 58. Stephen P. Meisser, Julie L. Glasser et al:
resistance training on pain and functioning Declines in strength and balance in older
among adults with osteoarthritis of the knee. adults with chronic knee pain: a 30 month
Arch Phys Med Rehabil, Vol. 83, September longitudinal observational study. American
2002. College of Rheumatology, Vol.47, 141-148,
54. Roy D. Altman, Marc C. Hochberg et al: April 2002.
Recommendations for the medical 59. Volga Bayrakci Tunay, Gul Baltaci et al:
managementt of osteoarthritis of the hip and Hospital based versus home based
knee. Arthritis & Rheumatism, Vol.43, proprioceptive and strengthening exercise
No.9, 1905-1915, September 2000. programs in knee osteoarthritis. Acta Orthop
55. S.R. Goldring and M. B. Goldring: Clinical Traumatol, 270-277, 2010.
aspects, pathology and pathophysiology of
-----[78]-----
EFFECTIVENESS OF SCAPULAR STABILITY EXERCISES IN THE

PATIENT WITH THE SHOULDER IMPINGEMENT SYNDROME
Maulik Shah1, Jayshree Sutaria2, Ankur Khant3
1. Assistant Professor, School of Physiotherapy, RK University
2. Lecturer, Government Physiotherapy College, Civil Hospital, Ahmedabad
3. Associate professor, School of Physiotherapy, RK University
ABSTRACT
BACKGROUND AND OBJECTIVES: The scapular musculature is often neglected in the evaluation and treatment of
shoulder injuries lead to scapular dysfunction which results in altered biomechanics of the shoulder girdle. Therefore
this study was designed to compare the effectiveness of Conventional Physiotherapy plus scapular stability exercises and
Conventional Physiotherapy alone on pain and functional status of the patients with shoulder impingement syndrome.
MATERIALS AND METHOD: Samples of 60 subjects with Shoulder Impingement Syndrome were divided randomly
into two groups, control group and clinical trial group. Each subject was treated for a period of 4 weeks, 6 days a week,
one session per day. Pre treatment and post treatment assessment was done using visual analogue scale (VAS),
shoulder pain and disability index(SPADI) and lateral scapular slide test(LSST).
RESULT: Paired and Unpaired t-tests were used for comparing control and clinical trial groups for post-treatment
effects. Both the groups shows improvement but Clinical Trial group showed extremely significant improvement in VAS,
SPADI and LSST score as compared to Control group.
INTERPRETATION AND CONCLUSION: Conventional exercise therapy plus scapular stability exercises is more
effective than Conventional exercise therapy alone in improving pain and functional disability in Shoulder Impingement
Syndrome patients.
KEYWORDS: scapular stability exercise, shoulder impingement syndrome, shoulder pain and disability index,
Lateral Scapular Slide Test
INTRODUCTION with SIS correlate with weakness of the scapula

thoracic muscles (lower stabilizers of the scapula
Shoulder disorders are the most common (Serratus anterior, rhomboids, middle and lower
among all peripheral joint disorders1. The term trapezii)) potentially leads to abnormal
“Shoulder Impingement Syndrome (SIS)” was 1st positioning of the scapula, disturbances in scapula
introduced by Neer in 1972. Shoulder humeral rhythm and generalized shoulder
impingement syndrome is a slowly progressive dysfunction10,11. A well-coordinated synergistic
disease. It describes symptoms and signs that co-contraction of Rotator cuff muscles & Scapular
results from compression of the rotator cuff Stabilizers is very necessary to anchor the scapula
tendons and the subacromial bursa between the and guide movement, thereby maintaining scapula
greater tubercle of humeral head and the antero humeral rhythm. The scapula moves through a
lateral edge of the acromion process2. Shoulder gliding mechanism in which the concave anterior
impairments, such as SIS has been associated with surface of the scapula moves on the convex poster
abnormal movement of the scapula during lateral surface of the thoracic cage. Cross
elevation of arm3-8. In addition, if an injury and/or sectional studies demonstrate that when the
biomechanical changes occur, it would lead to muscles are weak or fatigued, scapula humeral
impulsive or shear stress on distal part of the rhythm is compromised and shoulder dysfunction
Supraspinatus tendon, which may induce results11,12. This dysfunction can cause micro
progressive changes associated with shoulder trauma in the shoulder muscles, capsule, and
impingement syndrome. Weakness of the Ligamentous tissue and lead to
posterior scapular stabilizers can also be seen as a impingement11,13,14,15. Biomechanical studies
contributing factor to impingement syndrome by show that scapular stability exercises promotes
altering the mechanics of the Glenohumeral joint. posterior tilting, upward rotation and external
SIS has a detrimental effect on quality of life with rotation of the scapula. This normal biomechanics
shoulder elevation, sleeping, throwing, and of the scapula along with surrounding
working activities being most affected9. Pain and musculature is very vital to the overall normal
dysfunction occur when the shoulder is placed in function of the shoulder. Rotator cuff
positions of elevation, an activity that is common strengthening is the obvious treatment for the
during many vocational pursuits, ADL and treatment of the shoulder impingement syndrome
sporting. Ultimately these limitations lead to a but as the origin of the rotator cuff muscle arise
loss of functional independence and reduced from the scapula, an effective exercise regime for
quality of life. The disability and pain associated rehabilitation should include improving the
strength and function of muscles that control the
-----[79]-----
position of scapula. Weakness of these muscles Methodology

may lead to altered biomechanics of the 60 (Sixty) subjects were taken for the
Glenohumeral joint with resultant excessive stress study those fulfils inclusion criteria. They were
imparted to the rotator cuff and anterior capsule16. randomly divided into two groups, in control
Hence, primary aim of this study is to determine group only conventional treatment and in clinical
the effectiveness of the scapular stability exercises trial group, conventional treatment as well as
in patients with shoulder impingement syndrome scapular stability exercises were given. In
to improve pain and physical function. conventional treatment, progressive muscular
strengthening rehabilitation program was given
MATERIALS AND for Shoulder Flexors, Shoulder Adductors,
METHODOLOGY Shoulder Horizontal Adductors, Shoulder
Extensors, Side lying External Rotators,
An interventional study was conducted stretching of Pectoralis Major Muscles, Levator
to study the effectiveness of scapular stability Scapulae Muscle, Cross-Chest Stretch, Wand
exercises in the patient with the shoulder Exercises and Pendulum Exercises with
impingement syndrome at Physiotherapy Frequency: 3 sets of 8 repetitions, daily. In
Department, Civil Hospital, Ahmedabad. scapular stability exercise, Scapular clock
Convenient Random Sampling Method is used for exercise, Towel sliding exercise, The lawnmower
sample selection and duration of present study exercise, Prone Horizontal Abduction, Press up
was 4 weeks. The sample size of 60 (Sixty) plus exercise, Wall push up exercise and Scapular
patients were divided into two groups each PNF with Alternative weight Shifting. Each
consisting of 30 (Thirty) subjects: Control Group subject of the study was treated for a period of 4
& Clinical Trial Group. weeks, 6 days a week, one session per day. An
Inclusion Criteria: Age group: 20-60 assessment was done prior to starting of treatment
years, Genders: Male & females, Pain with and after 4 weeks of treatment, again assessment
resisted isometric abduction, Painful arc of was taken for these subjects.
movement between 600-1200, Pain with palpation
of the rotator cuff tendons, Positive Neer sign, RESULTS
Positive Hawkins test, Patients who are able to
comprehend commands and Willingness to TABLE 1: GENDER DISTRIBUTIONS OF THE
participate in the study. SUBJECTS
Exclusion Criteria: History of cervical Control Group Clinical Trial Group
Gender
and/or thoracic pathology, Previous neck or 12 (40%) 19 (63.33%)
Male count (%)
shoulder surgery, Previous shoulder injury in the 18 (60%) 11 (36.66%)
Female count (%)
past 6 months, Reproduction of shoulder 30 (100%) 30 (100%)
Total
symptoms during active cervical movements,
Systemic illness, Presence of shoulder instability
based on a positive sulcus test, anterior or
posterior apprehension tests, History of spinal or
upper limb fracture and Pregnancy.
Materials : Consent Form, Assessment
Form, Examination Table, Scale, marker,
measuring tape, Standard Goniometer, Dumbbell,
Therabend, Ball for stabilizing exercise, Towel,
Wand and Kodak 3x Zoom 13 megapixel Digital
Camera.
A written informed consent of all the
subjects was taken prior to the study. Pre- FIGURE 1: AGE DISTRIBUTION OF THE
participation evaluation form consisted of SUBJECTS
shoulder pain and disability index, descriptive
data for age, sex, height, weight, duration of TABLE 2: MEAN CHANGES IN SPADI BEFORE
symptoms in affected shoulder joint, previous AND AFTER INTERVENTION
surgery, medications, exercise frequency, history, Pre treatment Post treatment
t value p value
Groups Mean ±SD Mean ±SD
chief complaints, Visual Analogue Scale (VAS)
Group A 73.26 7.679 46.06 6.080 36.589 < 0.0001
score for pain, active and passive ROM, manual
Group B 74.53 12.403 31.8 6.19 30.39 < 0.0001
muscle testing, palpation of shoulder girdle with
surrounding musculature, etc.
-----[80]-----
TABLE 3: MEAN CHANGES IN SPADI

(RESULTS OF UNPAIRED T-TEST)
t value P value
SPADI 9.470 P< 0.0001
FIGURE 4: MEAN LSST SCORE (BETWEEN

GROUP COMPARISON)
TABLE 7: MEAN CHANGES IN LSST

(RESULTS OF UNPAIRED T-TEST)
t value P value
LSST 4.965 P< 0.0001
DISCUSSION
FIGURE 2: MEAN CHANGES IN SPADI Shoulder impingement syndrome is one
(BETWEEN GROUP COMPARISON)
of the most common conditions that affect the
shoulder and accounts for 44-65% of all cases of
TABLE 4: MEAN CHANGES IN VAS BEFORE
AND AFTER INTERVENTION shoulder pain. The symptoms affect the activities
of daily living which consequently deteriorate
Pre treatment Post treatment
Groups Mean ±SD Mean ±SD
t value p value quality of life. To date, there have been several
Group A 8.30 0.73 4.78 0.76 29.42 < 0.0001 studies investigating biomechanics or
Group B 8.78 0.73 4.01 0.65 30.75 < 0.0001 Pathomechanics in patients with Shoulder
impingement syndrome. This study investigates
TABLE 5: MEAN CHANGES IN VAS (RESULTS the association between scapular stability
OF UNPAIRED T-TEST) exercises and symptomatic relief in patients with
Shoulder impingement syndrome.
t value P value
In a study carried out by Wang et al., the
6.77 P< 0.0001
VAS success rate of conservative management in
patients with SIS was 73.8% regardless the
morphology of acromion. If the patient remain
significantly disabled and has no improvement
after conservative treatment, surgical treatment
may be considered.
While considering conservative
treatment for SIS, emphasis should be on tight
anterior chest wall muscles & weak Scapular
stabilizers. The main stabilizers are the Levator
Scapulae, Rhomboids Major & Minor, Serratus
Anterior & Trapezzi. The Glenohumeral
FIGURE 3: CHANGE IN VAS BETWEEN protectors include the muscles of the rotator cuff:
GROUPS A AND B the Supraspinatus, Infraspinatus, and Teres Minor
& Subscapularis. Synergistic co contraction of
TABLE 6: MEAN CHANGES IN LSST BEFORE
these muscles is necessary to anchor the scapula
AND AFTER INTERVENTION
& guide the movement of the shoulder girdle.
Pre treatment Post treatment Fatigue or weakness of the Scapular stabilizers
Groups (mm) (mm) t value p value
Mean ±SD Mean ±SD lead to compromised scapula humeral Rhythm
Group A 109.23 16.25 101.13 13.94 6.76 < 0.0001 and resultant Shoulder dysfunction that further
Group B 115.86 22.49 96.1 18.85 9.77 < 0.0001 leads to micro trauma in shoulder muscles,
capsule & Ligamentous tissue and leads to
impingement.
During overhead activities, Scapula must
rotate upwards, tilted posteriorly & rotated
externally. Weakness of the Scapular stabilizers
leads to imbalance of the force couples between
the Trapezzi, Serratus Anterior & Rhomboids that
-----[81]-----
may result in to downward rotation, anterior the groups. In Control Group, there were 12 males
tilting & internal rotation of the scapula during the and 18 females where as in Clinical Trial Group;
abduction of the arm resulting into narrowing of there were 19 males and 11 females.
the Subacromial space with the compression of There was no significant difference in
the underlying structures. This fatigue induced the age distribution of both the groups (Table 2).
strength deficit may result into the adverse effect The mean age of Control Group was 46.96 and for
on scapular position & allowing more lateral Clinical Trial Group it was 46.9.
gliding of the scapula during functional activities. In a series of 30 subjects with Shoulder
Every exercise programme should be impingement syndrome in Control Group, an
begin with stretching exercises. Weak muscles improvement in pain and physical function was
cannot be strengthened if their antagonistic observed after 4 weeks of treatment with
counter parts are not stretched. So stretching of the Conventional physiotherapy. There was also a
Pectoralis Major, Pectoralis Minor, Levator significant improvement in VAS, SPADI &
Scapulae is very necessary for the prevention of LATERAL SCAPULAR SLIDE TEST in all the
rounded shoulder posture which inhibits scapula subjects in Control Group.
humeral rhythm. In a series of 30 subjects with Shoulder
Strengthening of the rotator cuff muscles impingement syndrome in Clinical Trial Group,
are very necessary for the prevention of the there was extremely significant improvement in
upward translation of the head of humerus during pain and physical function after 4 weeks of
abduction that is caused by pull of deltoid. Since Conventional physiotherapy and scapular stability
the attachment of the Rotator Cuff muscle is on exercises. There was extremely significant
Scapula, a stable base is very necessary for the improvement in VAS, SPADI & LATERAL
proper functioning of the Rotator cuff. SCAPULAR SLIDE TEST in all the subjects in
The scapular stability exercises include Clinical Trial Group.
core exercises that include Scapular clock Both treatment groups obtained
exercise, Towel sliding exercise, alternate weight successful outcomes as measured by considerable
shifting exercise, Scapular PNF patterns, reduction in VAS scores, improvement of SPADI
Lawnmower exercise, that improves the force & improvement in LSST at the end of 4 weeks but
couples between Lower Trapezius & Serratus the improvement is much better in the clinical trial
anterior, both the Trapezzi & Rhomboids, thus group which receives Scapular stability exercises
maintaining the proper posterior tilting, upward along with strengthening of the Rotator cuff
rotation and internal rotation during functional & muscles.
overhead activities. These improved scapular Some people with shoulder impingement
position decreases impingement and increase syndrome avoid exercise because of joint pain.
rotator cuff efficiency. However, a group of exercises called "isometrics"
Impingement and injury to the Rotator will help strengthen muscles without moving
cuff muscle could result into damage to the neural painful joints. Isometrics involve no joint
mechanoreceptors that mediate normal movement but rather strengthen muscle groups by
Proprioceptive sensation of the shoulder. This using an alternating series of isolated muscle
deficit could lead to slow protective reflexes, contraction and periods of relaxation. “Isotonic”
where contraction of the muscles occurs too late is another group of exercises that involve joint
to protect the joint. Thus the resultant mobility. However, this group of exercises is more
proprioception deficit could contribute to further intensive, achieving strength development
deterioration of the condition. Lawnmower through increased repetitions or by introducing
exercise, alternative weight shifting & Scapular resistance.
PNF are responsible for improved proprioception Application of High TENS will result
& better strength of scapular stabilizers with into Relief of the pain and assosiciated Spasm of
improved efficiency of the Rotator cuffs in the Shoulder girdle muscles. This relief of pain &
elevating the arm. spasm is associated with the peripheral blocking
Of the 60 subjects, 30 subjects were kept of nociception by high frequency of the TENS that
in Control group with conventional exercise blocks the traffic in both A delta (fast) and C
therapy alone and the remaining 30 in the Clinical (slow) pain fibers in the posterior horn due to
trial group were given additional scapular stability stimulation of mechanoreceptors ( A beta) fibers
exercises. Lateral Scapular Slide Test, Shoulder by high frequency, low intensity electric pulses.
Pain and Disability Index & Visual Analogue Results indicate that there is extremely significant
Scale were taken before and after the treatment of improvement in Pain and Functional Status in
4 weeks. patients with Shoulder impingement syndrome at
The gender distribution of the subjects the end of 4 weeks after giving conventional
who participated in the study (Table 1) shows that exercise therapy and scapular stability exercises in
there is no significant sex preponderance in both the Clinical trial group than control group.
-----[82]-----
These findings support the idea that CLINICAL APPLICATION:

indeed, strengthening programs for rotator cuff
muscles & muscles of the Glenohumeral joints While treating any patient with shoulder
along with short anterior chest wall muscles are pain and dysfunction, Emphasis Should be on
beneficial for shoulder impingement syndrome scapular stability exercises. Though the Rotator
subjects but additional scapular stability exercises cuff muscles are chief stabilizers for Gleno
undoubtedly increases the relief score. humeral joint, but their origin is from the scapula.
So until they have a very stable base, they cannot
LIMITATIONS work effectively. So each treatment protocol for
any patient with shoulder dysfunction must
 The study consisted of only a small quantity contain exercises to strengthen the scapula.
of subjects; which should be revised to a large
number of subjects and for a longer duration
REFERENCES
of period.
 This was a short term study of 4 (four) weeks
1. Y.P.C.Lo, Hsu Y CS, Chan KM.
and no further follow up of subjects were
Epidemiology of shoulder impingement in
carried out.
upper arm sports events. Br J Sports Med.
 Home programme taught to the patients was 1990; 24 (3): 173-177
not supervised. 2. Wasilevsky SA, Frankal U. Rotator cuff
 Follow up was done at each week, but could pathology. Arthroscopic assessment and
not be described here as the significant result treatment. Clin Orthop. 1991; 267:65-70
need duration of at least 4 weeks. 3. Hebert LJ, Moffet H, Mcfadyen BJ, Dionne
CE. Scapular behavior in shoulder
CONCLUSION impingement syndrome. Arch Phys Med
Rehabil.2000; 83:60-69
The results of this study on 60 patients 4. Lukasiewicz AC, McClure P, Michener L,
with shoulder impingement syndrome has Pratt N, Sennett B. Comparisons of 3-
supported hypothesis of this study that There will dimensional scapular position and orientation
be significant relief with the use of the scapular between subjects with and without shoulder
stability exercises in the patient with the shoulder impingement. J Orthop sports Phys Ther.
impingement syndrome. Hence, it was concluded 1999; 29 (10): 574-586
that there is significant difference between 5. Borated JD, Ludewig PM. Comparisons of
Conventional exercise alone and Conventional scapular kinematics between elevation and
exercise therapy along with scapular stability lowering of the arm in scapular plane. Clin
exercises in relieving pain and improving physical Biomech. 2002; 17:650-659
function in shoulder impingement syndrome as 6. Ludewig PM, Cook TM. Alternation in
seen with Visual Analogue Scale, Shoulder Pain shoulder kinematics and associated muscle
And Disability Index and Lateral Scapular activity in people with symptoms of shoulder
Stability Test. impingement. Phys Ther. 2000:80:276-291
After 4 weeks of treatment, the 7. Warner JJ, MIcheli LJ, Arslanian LE,
significant improvement in pain and functional Kennedy J, Kennedy R. scapula thoracic
status was observed in patients performing motion in normal shoulders and shoulders
Conventional exercise therapy as well as scapular with Glenohumeral instability and
stability exercises rather than performing impingement syndrome. A study using moiré
Conventional exercise therapy alone. topographic analysis. Clin Orthop. 1992:191-
On assessing few patients who came for 199
follow up, it was found that subjects in both 8. Cole A, McClure P, Pratt N. scapular
groups appeared less likely to be taking kinematics during arm elevation in healthy
medications for their symptoms of the shoulder subjects & patient with shoulder
impingement syndrome and were satisfied with impingement syndrome. J Ortho sports Phys
the overall outcome of their rehabilitative Ther. 1996; 23-68
programme. 9. Chipchase LS, O’Connor DA, Costi JJ,
Thus, it can be concluded that Krishnan J. Shoulder impingement
Conventional exercise therapy along with syndrome: preoperative health status. J
scapular stability exercises is effective than Shoulder Elbow Surg. 2000; 9:12-15.
Conventional exercise therapy alone in improving 10. Paine RM, Voight ML. The role of the
pain and functional disability in patients with the scapula. J Orthop Sports Phys Ther. 1993;
shoulder impingement syndrome. 18:386 –391.
11. Kamkar A, Irrgang JJ, Whitney SL.
Nonoperative management of secondary
-----[83]-----
shoulder impingement syndrome. J Orthop overhead athlete. J Orthop Sports Phys Ther.
Sports Phys Ther.1993; 17:212–224. 1993;18:427– 432
12. DiVeta J, Walker ML, Skibinski B. 15. Bigliani LU, Codd TP, Connor PM, Levine
Relationship between performance of WN. Shoulder motion and laxity in the
selected scapular muscles and scapular professional baseball player. Am J Sports
abduction in standing subjects. Med.1997; 25:609–613.
13. Pink M, Jobe FW. Shoulder injuries in 16. Michael L. Voight, Brian C. Thomson: The
athletes. Clin Manage. 1991; 11:39–47. Role of the Scapula in the Rehabilitation of
14. Jobe FW, Pink M. Classification and Shoulder Injuries. Journal of Athletic
treatment of shoulder dysfunction in the Training 2000;35(3):364–372
-----[84]-----
PREVALENCE OF LOW BACK PAIN DUE TO ABDOMINAL

WEAKNESS IN COLLEGIATE YOUNG FEMALES
Parashar P1, R. Arunmozhi2, Kapoor C3
1. Primary Researcher, SBSPGI, Dehradun
2. MPT (Sports & Rehabilitation), Associate Professor in Physiotherapy, SBSPGI, Dehradun
3. Kapoor C, MPT (Sports Rehabilitation), Assistant Professor in Physiotherapy, SBSPGI, Dehradun
ABSTRACT
Aims and Objectives: To find out that abdominal muscle weakness is one of the causes of low back in girls between the
age group of 18-25 years.
Methodology: 400 assessment forms were distributed among the female subjects of Mata Gujri Girls Hostel, Dehradun.
362 filled forms were received from the subjects. The subjects falling in the age group 18-25 years were looked for
presence of low back pain and the strength of their abdominal muscles were assessed by Daniel & Worthingham’s Manual
muscle testing. The data was analyzed using percentage method.
Results: 76 (21%) out of 359 subjects were suffering from low back pain. Out of 76 subjects 47.3% i.e. 36 subjects were
suffering from weakness of trunk flexors and 52.6% i.e. 40 subjects were suffering from weakness of trunk rotators.
Conclusion: After analysis, the result shows that low back pain is related to abdominal weakness.
KEYWORDS: Abdominal weakness, low back pain
INTRODUCTION Core strengthening has become a major

trend in rehabilitation. The term has been used to
Low back pain is usually defined as pain, connote lumbar stabilization, motor control
muscle tension, or stiffness localized below the training and other regimens. Core strengthening
costal margin and above the inferior gluteal folds, is, in essence, a description of the muscular
with or without leg pain (sciatica). Low back pain control required around the lumbar spine to
is typically classified as being ‘specific’ or ‘non- maintain functional stability. Despite its
specific’. Specific low back pain is defined as widespread use, core strengthening has had
symptoms caused by a specific patho- meager research. Core strengthening has been
physiological mechanism, such as hernia, promoted as a preventive regimen, as a form of
infection, inflammation osteoporosis, rheumatoid rehabilitation, and as a performance enhancing
arthritis, fracture or tumour. Non-specific low program for various lumbar spine and
back pain is defined as symptoms without clear musculoskeletal injuries5.
specific cause, i.e. low back pain of unknown We could not find any literature on the
origin15. Few cases of back pain are due to prevalence of low back pain due to abdominal
specific causes; most cases are non-specific. muscle weakness in females between the age
Acute back pain is the most common presentation group of 18-25 years. Therefore the present study
and is usually self-limiting, lasting less than three is a search to find out whether the abdominal
months regardless of treatment. Chronic back pain weakness is one of the reasons for low back pain.
is a more difficult problem, which often has strong
psychological overlay: work dissatisfaction, METHODS
boredom, and a generous compensation system
contribute to it4. Total 400 assessment forms were
Back pain is a common problem and distributed. Only 362 filled up forms were
was recently thought to affect 17.3 million people received from the subjects. Out of 362, 79 subjects
in the UK. Up to 10% of sufferers have chronic were suffering from low back pain. 3 subjects
back pain6. In the United States, the National were excluded due to age limit and abdominal
Arthritis Data Workgroup reviewed national muscle strength was assessed of the 76 subjects.
survey data showing that each year some 15% of 40 subjects were suffering from trunk flexors and
adults report frequent back pain or pain lasting 36 from trunk rotators weakness. 36 subjects were
more than two weeks13. LBP in children and not suffering from any muscle weakness. Data
adolescents, as in adults, is a common condition: was analyzed using percentage method and results
some have shown lifetime prevalence as high as were calculated.
70–80% by 20 years of age. In addition, several
studies have calculated new onset rates of around
20% over a1–2 year period. Pain prevalence
increases with age and is higher in girls than
boys10.
-----[85]-----
RESULTS suffering from low back pain 47.3% of the

subjects were suffering weakness of trunk flexors
The results were analyzed using the (internal oblique, external oblique & rectus
percentage method. The results showed that out of abdominis) and 52.6% subjects were suffering
the 359 subjects about 22% i.e. 76 were suffering from weakness of trunk rotators (internal oblique
from non specified low back pain, and out of that & external oblique). Keeping in mind the results
about 47% i.e. 36 subjects were suffering from of our study we can say that abdominal weakness
weakness of trunk flexors (rectus abdominis, has a major role in low back pain.
obliquus externus & obliquus internus) and 51% Asfour & Ayoub (1984) have
i.e. 39 subjects were suffering from weakness of suggested that back and abdominal muscle
trunk rotators (obliquus externus & obliquus strength may protect against back injuries, as
internus). (Refer figure 1, 2 and 3) strong muscles may alleviate part of the
mechanical stresses on the spine. Findings have
been inconclusive and it has been suggested that
back pain also leads to muscle weakness,
therefore this weakness may be the result of back
pain rather than its cause1. Hodges & Richardson,
(1996) stated that the delay in onset of contraction
of trunk muscles associated with movement of the
upper limb in patients with low back pain
indicates a significant deficit in the automatic
motor command for control of disturbance to the
spine8. Also Selen et al (2003) proposed that the
alterations in trunk muscle recruitment in patients
FIGURE 1: PREVALENCE OF LOW BACK with low back pain are functional in that they
PAIN reduce the probability of noxious tissue stresses
by limiting range of motion and providing
stabilization of the spine14.
Ferguson et al (2004) found that the
normalized time of muscle activation was longer
in the low back pain symptomatic patients than in
the asymptomatic participants. The increased time
of muscle activation has a ‘‘cost’’ in terms of
spine loading. The cost is that the low back pain
group would be exposed to increased spine
FIGURE 2: GRADES OBTAINED IN MMT OF loading due to muscle activation for a longer
TRUNK period of time when performing the same task as
an asymptomatic control5. Norbaksh & Arab
(2002) stated that Electromyographic (EMG)
studies, indicate that the paraspinal muscles in
patients with low back pain have a faster fatigue
rate compared with those in asymptomatic
subjects12.
On contrary, Lederman (2007) stated
that weak trunk muscles, weak abdominals and
imbalances between trunk muscles groups are not
FIGURE 3: GRADES OBTAINED IN MMT OF
pathological, just a normal variation. Weak or
TRUNK ROTATORS dysfunctional abdominal muscles will not lead to
back pain. Tensing the trunk muscles is unlikely
to provide any protection against back pain or
DISCUSSION reduce the recurrence of back pain11. Also Helewa
et al (1999) suggested that more frequent exercise
The present survey was designed to
reviews and a more intensive exercise programme
analyze the prevalence of low back pain due to
could have yielded better results but at a
abdominal weakness in collegiate females within
considerably higher costs7.
the age group 18-25 years. A total 362 female
Some of the other causes of low back
subjects with mean age 21.5±1.15 were surveyed
pain have been identified in different studies on
and the result was obtained using the percentage
different populations, e.g. emotional problems;
method. The analysis indicated that the
conduct problems, and other common childhood
prevalence of low back pain in the given
complaints17, occupation13, dynamic sacro-iliac
population was 21.1%. Out of the total population
-----[86]-----
joint instability from mal-recruitment of gluteus December 2007;74(12):905-13.

maximus and biceps femoris muscles9, sprains, 20. Ehrlich GE. Low back pain. Bulletin of the
strains, or degenerative changes in the muscles, World Health Organization 2003;81:671-676
disks, and connective tissues of the back itself3. 21. Ferguson SA, Marras WS, Burr DL ,Davis
As the prevalence rates of low back pain KG, Gupta P. Differences in motor
are high in any population, it is important to recruitment and resulting kinematics between
prevent first time occurrence of low back pain as low back pain patients and asymptomatic
well as to prevent acute low back pain from participants during lifting exertions. Clinical
becoming chronic and recurrent. This is possible Biomechanics 19 (2004) :992–999
by identifying the commonest cause of low back 22. Forward DP. Angus W. Low back pain. 2008
pain in each age group and alleviating those September, Synopsis of causation, Ministry
causes in the corresponding age group. Thus there of defense.
are evidences that low back pain is related to 23. Helewa A, Goldsmith CA, Lee P, Smythe
abdominal muscle weakness. The mechanism HA, Forwell L. Does strengthening the
may be that muscle weakness results in muscle abdominal muscles prevent low back pain- a
imbalance and compensatory movements both of randomized controlled trial. Journal of
which or anyone of these two factors may lead to Rheumatology,1999:26:1808-15
pain, the same will be applicable to abdominal 24. Hodges PW, Richardson CA. Inefficient
muscle weakness and low back pain. The other Muscular Stablization of the lumbar spine
possible mechanism may be the deconditioning associated with low back pain. Spine
theory. Most people with ordinary backache have 1996;21(22):2640-50
much less extreme degrees of deconditioning but 25. Hossain M, Nokes LD. A model of dynamic
the general principle is the same. Reduced activity sacro-iliac joint instability from
of any degree causes loss of functional capacity. malrecruitment of gluteus maximus and
The effects are reduced and guarded movements, biceps femoris muscles resulting in low back
loss of muscle strength and endurance & pain. Medical Hypotheses 2005; 65 (2):278-
stiffness16. 81.
Limitations of this study were that the 26. Jones GT, Macfarlane GJ. Epidemiology of
results of MMT were solely dependent on the low back pain in children and adolescents
basis of observation of the examiner so they are Arch Dis Child 2005;90:312–316.
not free from errors and no data could be obtained 27. Lederman E.The myth of core stability.
about whether abdominal weakness was present CPDO Online Journal; 2007 June:1-17
before the onset of low back pain or not. The study Available from the URLwww.cpdo.net
can be carried out on male subjects or on a 28. Nourbakhsh MR, Arab AM. Relationship
different age group, relation of isolated muscles Between Mechanical Factors and Incidence
with low back pain can be examined. of Low Back Pain. J Orthop & Sports Phys
ther, 2002 September; 32(9):447–60.
CONCLUSION 29. Punnett L, Ustün AP, Nelson DI, Fingerhut
MA, Leigh J, Tak SW et al. Estimating the
The present study shows that low back global burden of low back pain attributable to
pain is related to abdominal weakness. combined occupational exposures. American
journal of industrial medicine(preprint)
CLINICAL APPLICATION 30. Selen LPJ, Dieen JH , Cholewicki J. Trunk
muscle activation in low-back pain patients,
This study will help in the establishment an analysis of the literature. Journal of
of a relation between low back pain and Electromyography and Kinesiology 13
abdominal weakness. (2003) 333–351
31. Tulder MV, Koes B, Bombardier C.Low
REFERENCES back pain. Best practice &Research Clinical
Rheumatology 2002; 16 (5):761-777
17. Adams N, Taylor DN, Rose MJ, Ravey J. The 32. Wadell G, Nachemson AL, Phillips RB.The
psychophysiology of low back pain. back pain revolution.2nd ed . United
Singapore: Churchill and Livingstone;1997 Kingdom: Churchill Livingstione; 1998.
18. Akuthota V, Nadler SF. Core strengthening. 33. Watson KD, Papageorgiou AC, Jones GT,
Arch Phys Med Rehabil 2004; 85(3 Suppl 1): Taylor S, Symmons DPM, Silman AJ,
S86-92. Macfarlane GJ. Low back pain in
19. Bell G, Klineberg E, Demico R, Mazanec D, schoolchildren: the role of mechanical and
Orr D, Mclain R. Masquereade: Medical psychosocial factors .Arch Dis Child
causes of back pain. Cleveland Clinical J Med 2003;88:12–17
-----[87]-----
Publish your Article / Call for Papers
Guidelines for Authors

• Title of article should be “bold” with font size of 14 with authors’ name/names with their
designations and working institutes. Article should be sent in Microsoft Word format in
single file as attachment with font type “Times New Roman” with font size of 12.
• The graphs should be in 2 dimensions only with data label.
• Word limit for abstract and full article is 300 and 3000 respectively.
• Along with article, author has to send declaration form that it is original work done and has
not been sent to another journal at the same time in another separate file in Microsoft Word
format.
• Article should contain:
o Title
o Name(s) of Author(s) and Co-Author(s)
o Abstract (including key words)
o Introduction,
o Aims & Objectives
o Methodology (including Materials, Sample size, Study design, Study settings,
Sampling design, Inclusion criteria, Exclusion criteria, Technique etc)
o Results (including Tables, Graphs etc)
o Discussion (including Additional findings if any, Supporting and opposing articles,
Possible theoretical reasoning if any, Limitations, Future recommendations etc)
o Conclusion
o Acknowledgement if any
o Clinical application
o Reference (in Vancouver style)
• Policy of Reviewing
Indian Journal Of Physical Therapy is peer reviewed by panel of subject experts who are
duly blinded. The process of referring is anonymous and minimum of two independent
notions are taken on all the submitted papers. Associate editors are in the know of the
authorship.
• Ethics
Indiana Journal Of Physical Therapy is bounded and following code of conduct given by
WCPT. This code will guide the editorial board and reviewers in their approach to any
ethical issues arising in respect of papers submitted to Indiana Journal Of Physical
Therapy.
Send your article at editor@indianjournalofphysicaltherapy.com as word file attachment

Article Subscription
Institute 1000 INR (Print Only)
Individual 700 INR (Print Only)
Please Note
• Subscription rates are given here are for one year (2 Issues)
• Advance payment should be made by cheque/demand draft in the name of “Indian Journal of
Physical Therapy” payable at Rajkot.
• We do not currently have option for online subscription.
• Please contact the editor on details given on the website for subscription enquiry
Advertisement Rates
Internal Pages
Black and White Color
Full Page 3000 INR 4500 INR
Half Page 1600 INR ------------
Quarter Page 1000 INR ------------
Cover Pages (Color)

First --------
Second 6000 INR
Third 6000 INR
Fourth 7000 INR (Upper 7/8 area)
Please Note
• For Advertisement, advertiser should provide with either jpeg or pdf file
• The full page size mentioned here means standard letter/A4 size (8.5"x11")
• Half Page - half of full page by horizontal
• Quarter Page - half of half page by vertical
• Ads for cover page is only full page. No ad. for first page
• The Advertiser should pay in advance by Cheque/DD in name of "Indian Journal of Physical
Therapy" Payable at Rajkot
• For assistance contact editor on the details given on the website
INDIAN JOURNAL OF PHYSICAL THERAPY
SUBSCRIPTION FORM
Subscription Type (select the bracket for options)
( ) Individual ( ) Institution
Subscription Term (select the bracket for options)
( ) 1 Issue (Volume no ________ Issue no __________ ) ( ) __ Year
Name: _______________________________________________________________________________
Postal Address: ________________________________________________________________________
_____________________________________________________________________________________
Pin Code: _____________________________________________________________________________
Contact no: Office__________________ Residence _______________ Mobile no ___________________
Email: _______________________________________________________________________________
Profession: _________________________________Designation:________________________________
Payment by: (cheque or DD should be in favor of Indian Journal of Physical Therapy payable at Rajkot, Gujarat, India)
( ) Cheque (No: _______________, Date: ____________ )
( ) DD (No: ___________________, Date: ____________ )
( ) Cash (Ref No:_______________, Date: ____________ )
Note:- Cash can be directly deposited in following bank account (quote ref no. of transaction)
Bank Name : Indian Bank Account No : 6156194288
Account Type : Current Name : Indian Journal Of Physical Therapy
Branch : Rajkot Main Branch, Gujarat, India IFSC Code : IDIB000R007
MICR Code: 360019002 Branch Code : 00473
Date: _________________ Signature: ________________
Please fill in this order form duly & completely & mail it to
Dr Dinesh Sorani (MPT)

Editor (Indian Journal of Physical Therapy)
“MATRU ASHISH”
4-Kanaknagar Society,
Near Sant Kabir road,
Rajkot-360003
Gujarat, India
Published, Printed and Owned: Dr Dinesh Sorani (MPT)
Designed and Printed: R K Computers and Printers, Rajkot
Published at: “Matru Ashish”, 4-Kanaknagar society, Near Sant Kabir Road, Rajkot-360003
Editor:Dr Dinesh Sorani (MPT), Mobile: +91-9426786167, Email: editor@indianjournalofphysicaltherapy.com
View publication stats

IJPTVol2Iss1Jan Jun14 2

Uploaded by

Copyright:

Available Formats

IJPTVol2Iss1Jan Jun14 2

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

IJPTVol2Iss1Jan Jun14 2

Uploaded by

Copyright:

Available Formats

See discussions, stats, and author profiles for this publication at: https://www.researchgate.

MUSCULOSKELETAL PAINAND INJURY IN PROFESSIONAL DANCERS:

Article · June 2014

Happiness Anulika Aweto

Chest Physiotherapy for patients with COVID-19 View project

The user has requested enhancement of the downloaded file.

Dr. Anjali Bhise

Dr. Yagna Shukla

Dr. Sarla Bhatt

2 MUSCULOSKELETAL PAIN AND INJURY IN PROFESSIONAL DANCERS: PREVALENCE, PREDISPOSING 6

3 A STUDY TO EVALUATE THE HEMODYNAMIC RESPONSE TO REPETITIVE MCKENZIE EXERCISE IN 14

6 AWARENESS AND KNOWLEDGE OF PHYSIOTHERAPY AMONG THE GENERAL PUBLIC IN AN AFRICAN 32

7 A COMPARATIVE STUDY OF ULTRASOUND AND EXERCISE VERSUS PLACEBO ULTRASOUND AND 37

10 TO STUDY THE EFFECT OF PROPIOCEPTIVE NEUROMUSCULAR FACILITATION VERSUS WEIGHTED 51

11 EFFECTIVENESS OF MANUAL TRACTION OF TIBIO-FEMORAL JOINT ON THE FUNCTIONAL OUTCOME IN 56

12 DOES POLARIZED LIGHT THERAPY IMPROVE CHRONIC MAXILLARY RHINOSINUSITIS? 62

14 EFFECT OF BALANCE EXERCISES ON BALANCE, PAIN AND FUNCTIONAL PERFORMANCE IN 71

15 EFFECTIVENESS OF SCAPULAR STABILITY EXERCISES IN THE PATIENT WITH THE SHOULDER 79

DURATION OF MAINTAINED HAMSTRING FLEXIBILITY GAINS

KEYWORDS: Hamstring, Modified Hold-relax stretching, Active knee extension, flexibility

INTRODUCTION of flexibility gains after a single stretching session

DATA ANALYSIS result of prestretch Vs starting min (p=0.0001),

Active Knee Extension

Mean values and Standard Deviations of

Mean ± SD Mean ± SD p value

Russell P. Effect of stretching position on 9. Worrell TW, Smith TL, Winegardner J.

MUSCULOSKELETAL PAIN AND INJURY IN PROFESSIONAL

KEYWORDS: Musculoskeletal pain, injury, professional dancers.

puberty), extensive and intense rehearsals,

0.89) (Table 10), the type of dance (ℵ =

TABLE 3: HOW OFTEN THE RESPONDENTS

How often respondents had pain Frequency Percent

TABLE 4: SEVERITY OF PAIN FELT BY THE

TABLE 5: WHEN THE INJURY LIKELY

TABLE 6: CAUSES OF INJURY

TABLE 7: MISSING TRAINING OR PERFORMANCE DUE TO PAIN OR INJURY

TABLE 8: TYPES OF TREATMENT RECEIVED BY RESPONDENTS

Types of treatment received Frequency Percent

Figure 5: Areas of pain and injury due to different types of dance

Figure 8: Respondents’ modification of

Figure 9: Respondents who received

A STUDY TO EVALUATE THE HEMODYNAMIC RESPONSE TO

KEYWORDS: McKenzie exercises, Hemodynamic Response, RPP, BP

classify patients as having 1 of 3 syndromes

of these exercises, however, are typically not EXCLUSION CRITERIA:

TABLE 4: MEAN SCORES OF SBP, DBP, PR

Group-1 ( FIS ) SBP 111.6 113.8 125.2 137.2

Total number of subjects 80 Group-3 ( FIL ) PR 79 87.8 100.3 145.2

Mean 28.3000 Group-4 ( EIL ) PR 78.1 89.2 98.9 111.6

DISCUSSION exercises after 15 and 20 repetition in Group 1

cardiopulmonary function. Phys Ther. measurement by indirect cuff

COMPARISON OF THE EFFECT OF CHAIR RISING EXERCISE AND

INTRODUCTION and disabling conditions2. Thus, exercise aimed at

In geriatrics, it is important to reduce fear 2011; 14:489-95.

performance? A comparison of muscle cross functional capacity in communitydwelling

A STUDY TO FIND OUT THE CORRELATION BETWEEN HANDGRIP

INTRODUCTION assessment measure grip strength has been shown

METHODOLOGY extended between 0°- 30° & ulnarly deviated

Handgrip strength was measured using a