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Scientific Research Journal of India (Multidisciplinary, Peer Reviewed, Open Access, Journal of science)
ISSN: 2277-1700 Vol: 2, Issue: 3, Year: 2013
Editor in Chief
Dr. Krishna N. Sharma (PT)
Editors
Dr. Popiha Bordoloi
Dr. Kuki Bordoloi
Dr. Sudeep Kale
Dr. Waqar Naqvi
Junior Editor
Mrityunjay Sharma
Office Dr. L. Sharma Campus, Muhammadabad Gohna, Mau, U.P., India. Pin- 276403
Website http://srji.drkrishna.co.in
URL Forwarded to http://sites.google.com/site/scientificrji
Email editor.srji@gmail.com
Contact +91-9320699167
Declaration: The contents of the articles and the views expressed therein are the sole responsibility of the authors, and the
editorial board will not be held responsible for the same.
Copyright © 2013 Scientific Research Journal of India
All rights reserved.
CONTENTS
Title Author/s Department Page
Editorial Dr. Krishna N. Sharma i
Effect of core stabilization
training on endurance of trunk
extensor and functional capacity
in subjects with mechanical low
back pain
Ranjeet Kumar, Dr.
Prosenjit Patra Physiotherapy 1
Effect of trunk muscles
stabilization exercises and general
exercises on disability in recurrent
non specific low back ache
Kumar Amit, Gupta
Manish, Kumar Satish,
Katyal Taruna
Physiotherapy 9
Study of respiratory capacity and
core muscle strength in Indian
classical singers
Shweta S. Devare Phadke,
Sukhada Prabhu, Sujata
Yardi
Physiotherapy 18
Aerobic capacity, body mass
index and fat fold measurements
of healthy athletes in Dehradun –
A cross sectional study
Sharma Chetan, Dr. Dar
Shahid Mohd. Physiotherapy 24
Effects of bimanual functional
practice training on functional
performance of upper extremity in
chronic stroke
Dr Jasmine Anandabai,
Dr Manish Gupta Physiotherapy 30
A comparison study on physical
impairments and functional
limitations of patients: 1 year after
total knee arthroplasty versus
control subjects
Amit Murli Patel Physiotherapy 40
Respiratory physiotherapy in
triple vessel disease with post
coronary artery bypass grafting
surgery (CABG)
Shanmuga Raju P,
Renkha Rao, Rajendhra
Kumar J, SuryaNaryana
Reddy V
Physiotherapy 55
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iv
Occupational therapy marketing
indian prospective Koushik Sau Occupational Therapy 59
Annotated bibliography of studies
w.r.t statistical methods Neha Dewan Physiotherapy 67
i
EDITORIAL
Dear Readers! I am very pleased to present this issue of the Scientific Research Journal of India (SRJI).
With this issue. This issue of the multidisciplinary and open access Journal of science contains total 8 papers
in Physiotherapy, and 1 paper in Occupational Therapy. I hope you’ll find these papers informative.
Here I would like to bring one more thing to your notice that new and permanent URL is
http://SRJI.DrKrishna.co.in and it will be directed to http://sites.google.com/site/scientificrji .
Do drop a mail to us (editor.srji@gmail.com) if you have any comment and suggestion.
Happy Reading.
Regards,
Dr. Krishna N. Sharma
Editor in Chief
1
EFFECT OF CORE STABILIZATION TRAINING ON ENDURANCE OF
TRUNK EXTENSOR AND FUNCTIONAL CAPACITY IN SUBJECTS WITH
MECHANICAL LOW BACK PAIN
Ranjeet Kumar, MPT (Musculoskeletal Disorder)*, Dr. Prosenjit Patra, MPT
(Cardiopulmonary)**
ABSTRACT
STUDY OBJECTIVES: To determine the effect of Core stabilization training on trunk extensor endurance
and functional capacity in subjects with mechanical low back pain. DESIGN: Experimental study.
SETTING: All the Subjects were taken from Dolphin (PG) Institute Of Biomedical and Natural Science,
Dehradun and the community in and community in and around Dehradun. SUBJECTS: A total of 30 subjects
(M: 14, F: 16) were recruited for the study on the basis of inclusion and exclusion criteria after signing the
informed consent form. METHODS: A total of 30 subjects (M: 14, F: 16) were recruited for the study on the
basis of inclusion and exclusion criteria after signing the informed consent form. The subjects were then
divided into two groups, (Group A= Core Stabilization and Endurance Training & Group B= Endurance
Training). All the subjects were asked to perform 5 min warm-up exercise before the intervention. The total
duration of the protocol was 6 weeks and frequency of exercise performed is 3 times per weeks. OUTCOME
MEASURE: Trunk Extensor Endurance Test was measured using Prone Double Straight-Leg Raise Test, &
Functional Capacity was assessed using Modified Oswestry Disability Index. RESULTS: The result of the
study demonstrates that both the Groups showed significant improvement when comparison is made within
the groups with p=0.001 for both trunk extensor endurance test and functional capacity. However, Group A
shows significant improvement between the groups post intervention p=0.023 & p=.000 respectively.
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CONCLUSION: From the present study it can be concluded that core stabilization training is effective in
increasing trunk extensor endurance and functional capacity in subjects with mechanical low back pain.
KEY WORDS: Core stabilization training, Endurance training, Trunk extensor endurance, Mechanical low
back pain, Trunk Extensor Endurance
INTRODUCTION
Low back pain is one of the most common
and costly musculo-skeletal pain syndromes,
affecting up to 80% of people at some point during
their lifetime. The re-occurrence rate of low back
pain is high and these disorders often develop into
a chronic fluctuating problem with intermittent
flares.6
Caring for chronic low back pain, is one of
the most difficult and unrewarding problems in
clinical medicine, as no approach to diagnose or
any form of treatment, has been shown to be
clearly definitive or effective. One possible
explanation for the inability to identify effective
treatment protocols is the lack of success in
defining groups of patients who are most likely to
respond to a specific treatment approach.6 For most
patients with acute low back pain, the etiology is
thought to be a mechanical cause involving the
spine and surrounding structures.12 A wide range
of terms is used for non-specific mechanical
causes, including low back strain/sprain, facet joint
syndrome, sacroiliac syndrome, segmental
dysfunction, somatic dysfunction, ligamentous
strain and myofascial strain.3
Biomechanics may be altered due to low
back pain or injury to the spine, producing
weakness and loss of muscle control, which leads
to further injury because the joints are not
appropriately supported again, this may result in
over-compensation by the pelvis or lower
extremities, which will increase the predisposition
to chronic injuries.5
The core has been described as a box with
the abdominals in the front, paraspinal and gluteals
in the back, the diaphragm as the roof and the
pelvic floor and hip girdle musculature as the
bottom. Therefore, the core serves as a muscular
corset that works as a unit to stabilize the body and
spine.1
Panjabi (1992) describe the spinal
stabilization system is conceptualized as consisting
of three subsystems; passive muscular skeletal
subsystem, which includes vertebra facet
orientation, intervertebral disc, spinal ligament and
joint capsules, as well as the passive mechanical
properties of the muscles. The active muscular
skeletal subsystem consists of muscles and tendons
that surround the spinal column. The neural and
feedback subsystem consists of various force and
motion transducers located in ligaments, tendons,
muscles and neural control centers. These passive,
active and neural control subsystems - although
conceptually separate - are functionally
independent. The passive subsystem does not
provide any significant stability to the spine in the
vicinity of the neutral position. It is towards the
ends of the ranges of motion that the ligaments
develop reactive forces that resist spinal motion.
The active subsystem is the means through which
the spinal stabilization system generates forces and
provides the required stability to the spine. The
Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013
3
magnitude of the force generated in each muscle is
measured by the force transducers (signal
producing devices) located in the tendons of the
muscles.15
Therefore, this aspect of the tendons may
be part of the neural control subsystem. Within the
neutral zone of motion, (that part of the range of
physiological intervertebral motion, measured
from the normal position, within which the spinal
motion is produced with a minimal internal
resistance - it is the region of high flexibility
around the mid-zone of motion) the restraints and
control for bending, rotating and shear force are
largely provided by the muscles that surround and
act on the spinal segment. The neural subsystem
receives information from the various transducers,
determines specific requirements for spinal
stability and causes the active subsystem to
achieve the stability goal.16
Well-developed core stability allows for
improved force output, increased neuromuscular
efficiency and a decrease in the incidence of
overuse injuries.9 The normal function of the
stabilization system is to provide sufficient
stability to the spine to match instantaneous
varying stability demands made by changes in
spinal posture, static and dynamic load.15 Hicks et
al, suggest that core stability system has a role in
ensuring spinal stability and according to van
Dillin et al. (2001), a decrease in spinal stability
places stress and excessive load on the spinal
joints and tissues, which eventually results in low
back pain.19
Control of back pain and prevention of its
occurrence can be assisted by enhancing muscle
control of the spinal segment through core stability
exercises. Therefore, exercise programs, which are
based on active rehabilitation, can reduce low back
pain intensity, alleviate functional disability and
improve core stability and back extension strength,
mobility and endurance.17
According to Chok et al. (1999), poor
endurance of the trunk muscles may induce strain
on the passive structures of the lumbar spine,
eventually leading to low back pain. Evidence
suggests that muscle endurance is lower for people
with low back pain than for individuals without
low back pain. Due to endurance being less in
trunk muscles, fatigue can affect the ability of
people with low back pain to respond to the
demands of an unexpected load. Fatigue, after
repetitive loading, also leads to loss of control and
precision, which may predispose an individual to
developing low back pain. Therefore, trunk muscle
endurance training has been recommended to
elevate fatigue threshold and improve
performance, thus, reducing disability of the
lumbar spine.4
Endurance training of back extensor
muscles, including the multifidus, has long been
recognized as a crucial preventative of recurrent
low back pain. The function and coordination of
the muscles that stabilize the lumbar spine,
especially the lumbar extensor muscles, are often
impaired in patients with low back pain.13
The role of trunk stabilizers is to retain the
musculature; to control, coordinate and optimize
function. Trunk fatigue, which occurs during
intense training or matches, produces a loss in
synchrony between upper and lower extremities,
which may cause a reduction in muscle strength.
This may in turn prevent a proper transfer of force
resulting in inappropriate compensation by the
body while performing a particular function.5
Dynamic trunk stability training includes
building muscle strength, endurance and using
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neuromuscular control to maintain dynamic trunk
stability.10
METHODOLOGY
An experimental study was conducted on 30
subjects (14 male and 16 female) who were
recruited from Dolphin (PG) Institute of
Biomedical and Natural Science and the
community in and around Dehradun based on the
inclusion and exclusion criteria and they were
divided into two groups after informed consent
was obtained. Group A (Core Stabilization and
Endurance Training) & Group B (Endurance
Training). Pre intervention measurement of Trunk
Extensor Endurance Test was measured using
Prone Double Straight2-Leg Raise Test, &
Functional Capacity was assessed using Modified
Oswestry Disability Index8. For both the groups 5
min of warm exercise was given before the
intervention. The total duration of protocol was 6
weeks and frequency of exercise was 3 times per
week.
Protocol for Group A: All subjects in this
group received Core stabilization training and
Endurance training on a Swiss ball.
1. Lunge
○ Sets-2
○ Repetition-8
○ Rest-1minute
2. Supine lateral roll.
○ Sets-2
○ Repetition-8
○ Rest-1minute
3. Abdominal crunch
o Sets-2
o Repetition-8
o Rest-1minute
4. Supine Russian twist
o Sets-2
o Repetition-8
o Rest-1minute
Protocol for Group B: All subjects in this group
received Endurance training on a Swiss ball.
1. Bilateral shoulder lifts
○ Sets-6
○ Repeatation-5
○ Rest-1 minute
○ Holding-20sec
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2. Contra-lateral arm and leg lifts
o Sets-2
o Repeatation-8
o Rest-1 minute
o Holding-20sec
3. Bilateral shoulder lifts with hands
behind the head
o Sets-2
o Repeatation-8
o Rest-1 minute
o Holding-20sec
4. Bilateral shoulder lifts with arms in
full elevation
o Sets-2
o Repeatation-8
o Rest-1 minute
o Holding-20sec
DATA ANALYSIS
Data was analysed using statistical package of
social sciences SPSS software (version 14.0). Pair
t-test was used for data analysis within the group
A and group B for Extensor muscle endurance test
and Modified Oswestry Low Back Pain Disability
Index. Independent t-test was used for data
analysis between the group A and group B for
Modified Oswestry Low Back Pain Disability
Index. The p value was set at (<0.05).
RESULTS
Data was analysed for 30 participants: 15
in each Group A & Group B.
Table1.1: Comparison of mean value for age
between group A and B
Table 1.2: Comparison of Pre and Post EET score
for group A and group B
Table1.3: Comparison of Pre and Post MODI
score for group A and group B
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Table 1.4: Comparison of Pre and Post EET score
between group A and group B
Table 1.5: Comparison of Pre and Post MODI
score between group A and group B
Results of the study showed that there is
improvement in trunk extensor endurance and
functional capacity after the intervention in both
the groups. This improvement in pressure
threshold was found to be statistically significant.
Group A (Trunk Extensor Endurance & Core
Stabilization) showed more improvement when
compared to Group A and this was found to be
statistically significant with p=0.023 & p=.000
respectively.
DISCUSSION
The present study investigated the effect
of core stabilization training on endurance of trunk
extensor and functional capacity in subjects with
mechanical low back pain. Endurance of Trunk
extensor and functional capacity was measured 2
times: pre-intervention and post-intervention
through prone double straight leg raise test and
Modified Oswestry Low Back Pain Disability
Index respectively. Subjects were divided into two
groups as Group A and Group B. Group A was
given Core stabilization training and Endurance
training on a Swiss ball and Group B was given
Endurance training on a Swiss ball. Both groups
received training three times a week for six weeks.
The changes observed in this study were
noteworthy. Within group comparison showed
significant changes with improvement in isometric
hold time and functional capacity in both groups A
and B. In between groups, statistically significance
difference was found in isometric hold time and
functional capacity.
According to Moffroid, Progression of
loading through postural changes produces
increases in endurance time of the back extensors,
as measured by the Sorensen Test. These postural
progressions increase the load moment on the
spine and thereby stress the erector spinae
muscles, multifidus and others.14
In addition adoptive changes occur in
skeletal muscle during endurance training ie,
slower rate of glycogenolysis, slower rate of
lactate production during submaximal exercise
occurs due to raise in the lactate threshold both in
absolute and relatives terms ie, o2 uptake(VO2)at
LT and vo2 max at LT, increased mitochondrial
enzyme activity and increase capillary density.7
Therefore, it is reasonable to expect
increased endurance of trunk extensor muscle in
group B subjects who only underwent endurance
training.
Core stabilization training has a theoretical
basis in treatment and prevention of various
musculoskeletal conditions.
Core stabilization training is hypothesized
to increase muscle activation by increasing motor
unit recruitment, rate and synchronization of
firing11
Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013
7
Richardson found that individual with low
back pain exhibits delayed activation of the
transversus abdominis muscle when compared
with normal individual. Low back pain patient
have an impaired ability to consciously contract
transversus abdominis and this is an important
component of abdominal stability training.17
Performance of exercises on unstable
surfaces like Swiss ball has been shown to increase
the activity of the rectus abdominis. It also causes
changes in muscle activity and force output and
may be another way of potentially altering
neuromuscular recruitment pattern17
Spinal instability occurs generally as a
result of delayed recruitment of core muscle/local
muscle like transversus abdominus, multifidus and
core stabilization training address these core
muscle, thereby increase spinal stability.17
Study by Kimitake Satoand Monique
Mokha has shown that core stabilization training
let to an increase in 5000meter run time
performance. The proposed mechanism was that
subjects who underwent core stabilization were
conscious of using their core muscle to stabilize
their running form. A similar mechanism may
exist in our study where by subjects who
underwent core stabilization training were able to
stabilize their form better during performance of
prone double leg raise test, thereby resulting in
longer hold times than subjects who only
underwent endurance training.18
So over all core stabilization training
increases muscle activation (transversus
abdominus, lumbar multifidus), alters
neuromuscular control and also increases spinal
stability, leading to decreased pain which may
have led to the increased isometric hold time and
functional capacity in group A subjects as
compared to subjects in group B.
Limitation of the study are sample size
was limited and no blinding was done during the
study. So the further recommendation for future
studies need to be done with broader dimensions,
EMG could be used to quantify the activation of
core muscle and it can also be used to track global
muscle activation during core stability testing.
Bio-mechanical marker can be measured.
CONCLUSION
From the present study it can be concluded that
core stabilization training is effective in increasing
trunk extensor endurance and functional capacity
in subjects with mechanical low back pain.
REFERENCES
1. Akuthota V. and Nadler, S.F. Core Strengthening. Physical Medicine and Rehabilitation. 2004; 85(1):
86-92.
2. Arab A M, SalawatiMahyar, Mohhammad E. Sensitivity, specificity and predictive value of the
clinical trunk muscle endurance tests in low back pain. Clinical Rehabilitation. 2007;21:640-647
3. Atlas, S.J. and Deyo, R.A. Evaluating and Managing Acute Low Back Pain in the Primary Care
Setting. Journal of General Internal Medicine. 2001; 16(2): 120-131.
4. Chok, B., Raymond. L., Latimer, J. and SeangBeng, T. Endurance Training of the Trunk Extensor
Muscles in People With Sub Acute Low Back Pain. Physical Therapy. 1999; 79(11):1032-1042.
ISSN: 2277-1700 ● Website: http://srji.drkrishna.co.in ● URL Forwarded to: http://sites.google.com/site/scientificrji
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5. Cholewicki, J. and McGills, S.M. Lumbar Posterior Ligament Involvement During Extremely Heavy
Lifts Estimated from Fluroscopeic Measurement. Journal of Biomechanics. 1992; 25:17-28. 8)
6. Dankaerts, W., O’Sullivian, P.B., Straker, L.M, Burnett, A.F. and Skouen, J.S. The Inter- Examiner
Reliability of a Classification Method for non- Specific Chronic Low Back Patients with Motor
Control Impairment. Manual Therapy.2005; 2:1-12.
7. Edward F, Coyle H, Martin, Susan A, Bloomfield, Oliver H, Lowry, John O, Holloszy. Effects of
detraining on response to submaximal exercises. J.Appl. Physiol.1985 59(3): 853-859
8. Fritz JM, Irrgang JJ. A Comparison of a Modified Oswestry Disability Questionnaire and the Quebec
Back Pain Disability Scale. Phys Ther 2001; 81:776-788.
9. Hedrick, A. Training the Trunk for Improved Athletic Performance. Strength and Conditioning
Journal. 2000; 22(3), 50-61.
10. Hubley-Kozey, C.L. and Vezina, M.J. Muscle Activation During Exercise to Improve Trunk Stability
in Men With Low Back Pain. Journal of Physical Medicine and Rehabilitation. 2002; 83(8): 1100-
1108
11. Kisner C, Colby LA. Therapeutic Exercise Foundations and Techniques. 5th ed.Philadelphia: F.A
Davis Company; 2007.
12. Krismer, M. and van Tulder, M. Low Back Pain (non-specific). Journal of Biomechanics. 2007;
21(1): 79-91.
13. Liebenson, C. Spinal Stabilization Training: The Therapeutic Alternative to Weight Training. The
Journal of Body Work and Movement Therapies. 1997; 1 (2): 87-90
14. Moffroid MT, Haugh LD, Haig AJ, et al. Endurance training of trunk extensor muscles. Phys Ther.
1993; 73:10 –17.
15. Panjabi, M.M. The stabilizing system of the spine, Part 1: Neutral zone and instability hypothesis.
Journal of Spinal Disorder. 1992; 5(4) 383 – 389.
16. Panjabi, M.M. The stabilizing system of the spine, Part 2: Neutral zone and instability hypothesis.
Journal of Spinal Disorders. 1992; 5(4): 390 – 397.
17. Richardson C.A. and Jull G.A. Muscle control-pain control. What exercise would you
prescribe?.Manual Therapy. 1995; 1: 2-10.
18. Sato K, Mokha M Does core strength training influence Running kinetics, lower-extremity stability,
And 5000-m performance in runners? Journal of Strength and Conditioning Research. 2009;
23(1):133-140
19. VanDillin, L.R., Sahrmann, S.A., Norton, B.J., Coldwall, C.A., Flemming, D., McDonell, M.K. and
Bloom, N.J. Effect of Active Limb Movements on Symptoms in Patients with Low Back Pain. Journal
of Orthopaedic and Sports Physical Therapy. 2001; 31 (8): 402-4144.
20. http://www.exercise-ball-exercises.com/list-free-exercise-ball-exercises.htm
CORRESPONDENCE
** Asst. Prof. Dolphin (PG) Institute, Dehradun (UK)
* Student Researcher, Dolphin (PG) Institute, Dehradun (UK)
9
EFFECT OF TRUNK MUSCLES STABILIZATION EXERCISES AND
GENERAL EXERCISES ON DISABILITY IN RECURRENT NON SP ECIFIC
LOW BACK ACHE
Kumar Amit*, Gupta Manish, Kumar Satish**, Katyal T aruna***
ABSTRACT
OBJECTIVE: To study the Effect Of Trunk Muscles Stabilization Exercises And General Exercises On
Disability In Recurrent Non Specific Low Back Ache. DESIGN: Pre-test and Post test control group design.
SETTING: Inpatient and rehabilitation hospital. PARTICIPANTS: A total number of 80 patients with
recurrent non specific low back pain are allocated randomly into 1 of 2 groups; control group received
general exercise only (n=40) and experimental group received specific stabilization (n=40)
INTERVENTION Both groups received 6 weeks exercise intervention with 30-40 min per session, thrice per
week and written advice. Main Outcome Measures: A Rolland Morris low back disability questionnaire were
used to measure disability. Outcomes were measured before and after intervention. RESULTS: The
calculated t-values for the RMDQ showed a significant variation at p=0.00. It showed that there is fulfilled
improvement in post test RMDQ values when compared to pretest ODQ values in both the groups. The mean
improvements between the two groups of low back pain patients were tested for significance using student t-
test. The calculated t-values for the RMDQ scale was significant at p=0.011. This shows that mean
improvement in the group II that received core strengthening is higher when compared to the group I that
received conventional exercise program. CONCLUSION: This study concludes that specific stabilization
exercise is beneficial in reducing disability and improved function in chronic non specific low back pain.
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KEYWORDS: Exercise, Low Back Pain, Stabilization, muscle, pain, disability
INTRODUCTION
Technological and organizational changes in
the industrial countries during last few decades
have markedly increased the number of jobs
performed in Monotonous and constrained
postures. Low back pain is one of the most
Common musculoskeletal health problem in the
industrialized countries affecting about 80% to
90% of the population at sometime during their
lives. Out of these 30% develop chronic low back
pain. Chronic low back disability appears to be
increasing faster than any other form of
incapacity1. Deep trunk muscles eg, transversus
abdominis and multifidus responsible for
maintaining the stability of the spine2. So
strengthening of these muscle and their restoration
should be effective in the management of
persistent LBP.Therapeutic workouts for
superficial and the deep muscles seem to be
effective in the treatment of CLBP3. Trunk
muscles exercises activate the abdominal and
paraspinal muscles as a whole and at a relatively
high contraction level4. There are many
randomized controlled trials RCTS on the
usefulness of classic trunk exercises5, 6, increasing
attention recently has been paid to the preferential
retraining of the local stabilizing muscles of the
spine7, 8. No randomized control trial has done that
stabilization training is beneficial in a sample of
patients with sub acute or chronic nonspecific low
back pain using pain and disability as outcome.
Two relevent randomized control trial have been
conducted in specific subgroup of patients with
low back pain7, 8. But, in these trial, the specific
effect of the trunk stabilization exercise regiment
was not compare to general back and abdominal
exercise. A more recent study that compared
stabilization exercise against 2 other general back
extensor exercise regiments in patients with
nonspecific chronic low back pain demonstrated
positive results for multifidus muscle
crosssectional area increase in favor of one of the
general exercise approach9. A study found that a
General exercise program can be improved in
reducing disability in short term than specific
stabilization and general exercises in subjects with
recurrent nonspecific low back pain10 Though
conventional back care exercises and stabilization
exercises are proved to be effective in chronic
mechanical low back pain patients, no literature
comparing the effectiveness on each other were
found which necessitated the present study to
compare the outcome of conventional and
stabilization exercises in in chronic non specific
low back pain.
METHODOLOGY
A total number of 80 subjects, with
nonspecific low back pain, were recruited from the
physiotherapy department of Sir Ganga Ram
Hospital, New Delhi, India. All the subjects to the
physical department were referred from orthopedic
outpatient after proper detailed assessment by an
orthopaedician. A total 150 subjects and
performed 120 subjects clinical evaluation by their
physician including radiograph images. 40 subjects
are dropped out and therefore sample consisted of
80 subjects with nonspecific CLBP.
Inclusion criteria were:
1. Patients who had a history of recurrent
LBP (repeated episodes of pain in past
Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013
11
year collectively lasting less than 6
months),
2. Patients who have nonspecific nature of
pain
3. Patients who are willing to participate in
the exercise program and willing to travel
independently to the hospital from the
home10
4. Mean age of subject is 30-50yr
5. Both gender are included.
Exclusion criteria were:
1. Patients with previous spinal surgery
2. Patients who have signs and symptoms of
gross spinal instability radiological
diagnosis of spondylolysis or
spondylolisthesis
3. Patients who had red flags suggesting
serious spinal pathology11.
4. Patients with cardio –pulmonary diseases
5. Patients with tumor, infection and fracture
6. Patients with rheumatic and inflammatory
condition
7. Patients with disc disease
8. Lumbar strain or sprain
9. Lumbar canal stenosis
10. Bowel and bladder dysfunction
The patients were not aware of the theoretical
basis of each of the exercise regimes but they were
briefed the study objective. All the subjects were
interviewed and examined by a clinical
physiotherapist of Sir Ganga Ram Hospital who
was unaware of their group. By using random
sampling method, the subjects with non specific
low back pain were assigned to 1 of 2 treatment
groups. Group–I received general low back
exercise only flexion and extension exercise and
group-II received specific trunk muscle
stabilization exercise . Functional disability were
assessed by the Rolland morris disability
questionnaires, were considered most appropriate
and yield reliable and valid data. Suitable patients
were asked to complete a number of
questionnaires of the Rolland Morris low back
pain disability questionnaire that were repeated
immediately and after 6 weeks. Interventions were
conducted over 6 weeks duration and each class
duration of 30-40 min for thrice per week for both
groups. Common components of the 2 programs
included Short wave diathermy given for 15
minutes to relieve pain.For Group-l, Simple classic
exercises for extensor Paraspinals and flexor
abdominals muscle groups were administrated
appendix. If subjects were able to progress each
week to a new level, on graded exposure exercise
principle, otherwise they remained at the same
exercise level.The exercises were repeated at
home, for a maximum of half an hour 3 times per
weeks, from the beginning of the program. For
Group-II, exercises were instructed as previous
recommendation appendix. The first session was
given individually for subjects assigned to this
group and lasted 30-45 minute. Initially exercises
with low intensityfor local stabilizing muscles was
initially administered with no movements
isometric and in minimally loading positions. The
holding time and the number of contractions were
increased progressively in these positions up to 10
contractions repetitions x 10 sec duration each 1st
and 2nd week. To ensure correct activation of the
transverse abdominis muscle was to observe a
slight drawing in maneuvers of the lower part of
the anterior abdominal wall below the umbilical
level consistent with the action of this muscle.
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Various tactile and pressure cues and auditory cues
were given to the patient to enhance the
contractions and to get maximum corrective
position and outcomes. Too much effort of initial
contraction of muscles was discouraged.
Integration with dynamic function through
incorporation of the stabilizing muscles’ co-
contraction into light function tasks was advised
next 4-6 weeks as soon as the specific pattern of
co-activation was achieved in the minimally
loading position and the subjects could
comfortable performed 10 contraction repetition x
10 sec duration each. A senior clinical physical
therapist assessed the outcome measures of this
study. All subjects received an information booklet
providing the latest scientific facts on low back
pain management at the beginning of the program.
RESULTS
The outcome of the data was analyzed, using
bar-graphical representation, mean, standard
deviation of the pre test and post test values of the
two groups individually. Comparison of mean
within the group was done and the difference of
mean, standard deviation between the group is also
done. Calculation was done according to M.S
excel soft ware.
The mean improvements between the two
groups of low back pain patients were tested for
significance using student t- test. The calculated t-
values for the RMDQ showed a significant
variation at p=0.00. It showed that there is fulfilled
improvement in post test RMDQ values when
compared to pretest RMDQ values in both the
groups., but the mean improvement in the group II
that received core strengthening is higher when
compared to the group I that received conventional
exercise program. The mean improvements
between the two groups of low back pain patients
were tested for significance using student t- test.
The calculated t-values for the RMDQ scale was
significant at p=0.011.
Table No 1: Comparison of disability (Rolland
Morris) within Control group.
The disability in the control group has
decreased post intervention, as in shown by their
means, Further analysis on the scores revealed
that these changes are statistically highly
significant in the control group (t=9.79, p=0.00)
Graph No 1: Comparison of disability ((Rolland
Morris) within control group.
Table No 2: Comparison of disability ((Rolland
Morris) within Experimental group.
Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013
13
The disability in the experimental group has
decreased post intervention, as in shown by their
means, Further analysis on the scores revealed
that these changes are statistically highly
significant in the control group (t=6.79, p=0.00)
Graph No 2: Comparison of disability within
experimental group.
Table No 3: Experimental Vs control group-
Disability (post pre difference)
The disability in the experimental & control
group has decreased post intervention, as in shown
by their means, though the change in the
experimental group was much higher than in the
control group. Further analysis on the scores
revealed that these changes are statistically
significant. (t=2.73, p=0.011)
Graph No 3: Experimental Vs control group-
Disability (post pre difference)
Interpretation:
The table-1and 2 showed that there is highly
significance difference between pre and post test
values of VAS within the groups. The calculated t-
values for the RMDQ showed a significant
variation at p=0.00. It showed that there is fulfilled
improvement in post test RMDQ values when
compared to pretest RMDQ values in both the
groups
The table-3 showed that there is highly
significance difference between pre and post test
values of RMDQ between the two groups.The
calculated p value showed a significance of
difference in improvement at p=0.011, which
indicates that experimental group has higher gains
in improvement in RMDQ scale than control
group.
DISCUSSION
Our findings suggest that stabilization
exercises reduce subject’s pain more effectively
immediately after the end of treatment protocol
over general exercise protocol with statistical
significant. The results of this study support the
initial hypothesis that specific exercise training of
the "stability" muscles of the trunk is effective in
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reducing pain in patients with chronically
symptomatic low back pain. Analysis of the pain
revealed that there is a difference in improvements
between both the groups. This treatment approach
was more effective than other conservative
treatment approaches which mainly involved
conventional exercise programs. This is in support
of Punjabi’s hypothesis that the stability of the
lumbar spine is dependent not solely on the basic
morphology of the spine, but also the correct
functioning of the neuromuscular system.
Therefore, if the basic morphology of the lumbar
spine is compromised, as in the case with
symptomatic CLBP, the neuromuscular system
may be trained to compensate, to provide dynamic
stability to the spine during the demands of daily
living.Consistent with these findings, McGill
reported that lumbar stability is maintained in vivo
by increasing the activity (stiffness) of the lumbar
segmental muscles, and highlighted the importance
of motor control to coordinate muscle recruitment
between large trunk muscles and small intrinsic
muscles during functional activities, to ensure
stability is maintained.
The trunk muscle stabilization exercise group
exercised the TrA and LM muscle14. In individual
with low back pain, the TrA has decreased
anticipatory capacity, meaning that it has reduced
segmental protective function15. Rodacki et al,
suggested that abdominal exercises are associated
with low back pain improvement, since during
abdominal contraction the pressure on the
intervertebral disks was decreased as a
consequence of the increased intra abdominal
pressure. However, no improvement on TrA
capacity were observed16. From methodological
point of view the frequency and duration of the
study were deemed appropriate to produce
demonstrable benefits, based on previous studies
of similar or less exercise duration5,17,15,18. Increase
in doses of exercise, increase in benefit of
exercise15. However, the stabilizing function of
trunk musculature is especially important around
the neutral posture, where the spine exhibits the
least stiffness. Increased neutral zone, a region of
low stiffness around the neutral spine had been
suggested first by Punjabi19. Richardson suggested
that the simultaneous isometric contraction
exercise for the local deep muscle TrA and LM is
most beneficial for re-educating the stabilizing
muscle and can incoporated with dynamic
functional exercise. In addition, both disuse and
reflex inhibition are likely to affect the slow twitch
or tonic holding contraction at a low level would
be most effective in retraining the stability
function of these muscle20. The other advantages
of core stability strengthening program is that, they
apart from improving core strength and stability
also improved flexibility, posture, ease of
movement, heightened body awareness, balance
and coordination. Hence, it showed more
significant in early phase of treatment than the
later phase. In non specific low back pain patients
the neutral zone muscles gets more affected than
the other muscles of back. Hence, early
rehabilitation of these muscles produced good
results within short time.
CONCLUSION
Both the exercise groups showed statistical
significance but stabilization exercise exercise
group showed more significant over general
exercise group in reducing disability in nonspecific
low back pain. Specific stabilization exercise
improves TrA and LM muscle activation capacity.
So specific stabilization exercise was superior in
Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013
15
reducing disability than general exercise group.
Limitation of the study were no intermediate
and long-term follow up examination.
Biopsychosocial factors were not observed in this
study.
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Physiologic and psychological benefits. Spine , 18(2), 232-8 (1993)
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or spondylolisthesis, Spine 22(24), 2959-67 (1997)
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three different training modalities on the cross-sectional area of the lumbar multifidus muscle
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exercise management manual therapy, 5(2),112 (2000)
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14. Segmental stabilization and muscular strengthening in chronic low back pain a comparative
study 65(10), 1013– 1017 (2010)
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18. Moffett J.K. and Togerson et al, Randomised controlled trial of exercise for low back pain,
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CORRESPONDENCE
*PhD Research Scholar , Singhania University, Pacheri Bari, RajasthanIndia
**Consultant, Sir Ganga Ram Hospital, New Delhi, India
***Asst. Professor, PDM Group Of Institutions, Bahadurgarh, Haryana, India
18
STUDY OF RESPIRATORY CAPACITY AND CORE MUSCLE STREN GTH
IN INDIAN CLASSICAL SINGERS
Shweta S. Devare Phadke*, Sukhada Prabhu**, Sujata Yardi***
ABSTRACT
Classical singers are elite athletes. Their art requires total mind & body integration. Body alignment
and breathing has an effect on phonation. Proper breathing technique leads to better control over breath and
quality of tone. Core muscles supports the work of lungs and larynx to produce better tone production and
ability to sing extended phrases and sustain notes for longer.1 OBJECTIVE: To compare core muscle
strength and respiratory parameters like peak expiratory flow rate and breathe holding time between Indian
classical singers and age matched non singers. METHODOLOGY: Group 1 Indian classical singers between
age group of 15 to 30 years, practicing minimum since 1 year. Group 2 Normal healthy adults between age
group of 15 to 30 years who are not engaged in any type of singing and fitness activity. After explaining
about the aims and objectives of the study , consent taken. Height, weight, core muscle strength assessment by
Richardson and Joule's grading, breath holding time and peak expiratory flow rate with mini Wright's peak
flow meter measured. The data was analyzed using GraphPadInstat Version3.10, 32 for Windows. RESULT:
The core muscle strength and Breath holding time of classical singers is significantly more than age matched
normals. There is mean difference in PEFR of singers and age matched normals which is statistically non
significant. The study reveals that singers have good core strength and breath holding time. For quality
singing training in breathing capacity and core muscle strength will help.
KEYWORDS: core muscle strength, indian classical singer, respiratory capacity.
19
INTRODUCTION
Singing requires exceptional co-ordination,
endurance and fine motor control. Body alignment
impacts vocal techniques. Breating capacity have
effect on specialised phonation like singing. 3 The
physiological effects of proper breathing
techniques are increased lung capacity, increase in
lung volume, improved all over stamina or
endurance of respiratory muscles, and better
oxygenation of entire body.1
According to Pilates, core strength and
stability is of tremendous benefit for breathing.
The core muscle encompasses all muscles that co-
ordinate the joints of lower spine, pelvis, hip and
stabilize lower torso. Most of these muscles also
assist in respiration. The core muscles help singers
to enhance endurance of respiratory muscles and
in turn increase the breathing capacity.3 If muscles
that support the breathing mechanism are well
toned, singing will be energy efficient.2 Core
muscles works by contracting the abdominal
muscles, creating higher pressure in abdomen ,
allowing diaphragms relaxation, upward rise to be
more carefully controlled. Core muscle gives
singer a means of controlling their sound or
phonation.1 Breath holding time is a rough index
of cardiopulmonary reserve measured by length of
time that a subject can voluntarily stop breathing
after a deep inspiration. Learning to catch and time
the breath for each song is critical for a quality
performance.5
Thus, we hypothesised, the core muscle
strength and respiratory capacity measured by
peak expiratory flow rate and breath holding time
of Indian classical singers are higher than age
matched healthy adults.
METHODOLOGY
� Type of study – Cross Sectional
� Study setting – Community Indian
classical singer
� Inclusion criteria – Indian classical singers
between age group of 15 to 30 years,
practicing minimum since 1 year.
Normal healthy adults between age group
of 15 to 30 years who are not engaged in
any type of singing activity.
� Exclusion criteria – Indian classical singers
with any lung or cardiac pathology (HTN,
pregnant women, within 6 months post
delivery ).
Singers engaged in any other physical exercise
or wind instruments.
Singers less than 1 yr of training and singers
who are not undergoing appropriate training.
Normal age matched adults involved in any
type of physical fitness activity.
MATERIAL USED
� Stabilizer’s pressure biofeedback unit
� Mini Wright’s peak expiratory flow meter
� Weighing scale
� Measuring tape and stop watch
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Procedure
1.Core muscle strength was measured by
Stabilizer’s pressure biofeedback unit, with help of
Richardson and Joule’s core muscle grading
method. This grading method was used as it is
reliable and valid method of testing core muscle
strength.18 The subject was instructed to be in
supine position with both lower limbs hip and knee
flexed. Drawing in maneuver i.e transverse
abdominis muscle activation was taught to the
subject. The inflatable bag was placed in lumbar
lordosis and pressure was raised till 40mm of Hg.
Subjects were instructed to take their umbilicus
upward and inward and maintaining this they were
graded as per following grades19-
1A- Unilateral heel slide, with other leg in hip
knee flexion resting on plinth.
1B- Unilateral heel slide with leg 5cms off the
plinth and other leg in hip knee flexion resting on
plinth.
2A- Unilateral heel slide with other leg off the
plinth in hip knee flexion.
2B- Unilateral heel slide with leg 5cm off the
plinth and leg off the plinth in hip knee flexion.
2. Peak expiratory flow rate was measured by Mini
Wright’s peak expiratory flow meter, a small
handheld device. Subject was in standing position
without any support. They were instructed to take
a deep inspiration through nose with device held in
mouth, and to blow out or expire forcefully
through mouth. 3 readings were taken, out of
which the best value was considered.17
3. Breath holding time was measured with the help
of stop watch. Subjects were in sitting position.
They were instructed to take a deep inspiration
through nose and to hold their breath as long as
possible. The normal duration was 30 seconds or
longer, diminished cardiac or pulmonary reserve
was indicated by duration of 20 seconds or less.5
RESULT
Table 1: Comparison of core muscle strength by richardson and joule’s grading
Singers Normals
Mean 2.9 1.433
Standard diviation 1.248 0.5683
'P' value <0.0001
Table 2: Comparision of breath holding time
Singers Normals
Mean 48.7 37.9
Standard diviation 9.963 8.588
'P' value >0.01 >0.01
Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013
21
Table 3: Comparision of peak expiratory flow rate
Singers Normals
Mean 371.33 359
Standard diviation 42.160 55.108
'P' value >0.10 >0.10
DISCUSSION
In our study, total 60 subjects participated, 30
in each group. Subjects were explained about the
study and a prior consent was taken. The age,
height (in cms), weight (in kgs), no.of training
years of the study subjects were noted. Subjects
were assessed on parameters like core muscle
strength, breath holding time, peak expiratory flow
rate (PEFR) in random order.
The data revealed that maximum no. of
singers are trained for 5-6 years. In order to
maintain homogeneous distribution these subjects
were matched based on age, height (singers- 160.4
cms, normals- 160.04 cms), and weight (singers-
61.66 kgs, normals- 60.86 kgs). The maximum no.
of study subjects assessed were females (singers-
86.6% and normals- 90%).
The statistical analysis shows that core
muscle strength of classical singers was
significantly high (P value-0.0009 ). This goes
along with our hypothesis that singers need to
build strength and flexibility throughout the torso.
The strong core muscle supports the muscles of
spine and lower ribs. which help to enhance rib
movement, resulting in improved breath capacity.
Thus core muscle strength if developed in proper
fashion helps to improve breath capacity in
singers.3 A good core encourages singer in
pushing. Pushing results when vocal cords are
squeezed together with such force that only
excessive breath pressure will allow them to
vibrate. If a singer tends to push, a stronger core
will make it possible to push a little harder.3 Core
strength and stability is of tremendous benefit for
breath co-ordination during singing. Core
strengthening exercises that strengthen the core
muscle along with abdominal muscle, back
muscle, muscle around pelvis are recommended
for singers as daily exercise program along with
their singing practice to sustain notes for longer
duration. This will also minimize work related
musculoskeletal disorders. Breath holding time of
classical singers is significantly higher than age
matched normals. Singers require a higher rate of
breath management capabilities as they need to
extend the normal breath cycle by maintaining
inspiratory position for as long as possible.3
Breathing strategies rely on ability to inhale a
substantial quantity of air and release it steadily.
This physiological mechanism of breathing is
relevant to singers as it provides energy to tone
and ability to sustain longer notes. Without
diaphragm and the muscles surrounding that
support its work, air can neither enter nor leave
from lungs. Without air expulsion the vocal cords
cannot vibrate and without vibration sound can’t
be produced.1 Cardiopulmonary fitness plays
important role in singing. It includes efficient
circulation of oxygen throughout the body and
ability to make good use of it.3 Efficient oxygen
consumption benefits singing techniques by
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22
allowing singer to sustain longer phrases. Building
strong core strength leads to less work of
breathing.3
There are 2 schools of teaching about breath
management 1 -
• Supporting the breath by compressing
abdomen during phonation (i.e. on
exhalation)
• Relaxing abdominal muscle as much as
possible during inhalation and phonation,
allowing diaphragm to work on inhalation
and riding its relaxation on outgoing
breath (i.e. during phonation)
In our study as breath holding time was higher
in singers so we would like to emphasis that
inspiratory training would help singers to sustain
notes for longer.
From the study it is evident that there is no
much significant difference in PEFR of singers as
compared to age matched normals. PEFR is
person’s maximum speed of expiration. PEFR
measures airflow through bronchi and thus degree
of obstruction in the airways.6 The PEFR values
of singer are nearly same as those of normals may
be because singers have to concentrate more on
inspiratory capacity and breath holding. Relaxed
and steady expiration is recommended for singers
to sustain longer notes.
Thus cardiopulmonary fitness and core muscle
strengthening plays important role in improving
quality of singing. The study reveals that singers
require good core strengthening and breath holding
time for quality singing. Hence clinically singer
fitness programme must include core muscle
strength training and breathing exercises.
Acknowledgements
We are heartily thankful to Yashsree Sangeet
Vidyalaya,Kalva and the staff of Dept. Of
Physiotherapy, Pad.Dr.D.Y.Patil University, who
supported us from the preliminary stages of the
project.
Conflict of Interest
We, Phadke S,Prabhu S, Yardi S state that
there is no conflict of interests with other people or
organizations about our work.
Source of funding
Study was self funded.
Ethical Clearance
Study has cleared by ethical committee of
Padmashree Dr. D.Y. Patil University.
REFERENCES 1. Sing wise effective and proper breathing- An information based resource for singers. Karyn O’
Connor, 2011, page no1.
2. Sing wise effective and proper breathing- An information based resource for singers. Karyn O’
Connor, 2011, page no2.
3. Sports specific training for vocal athlete- how exercise can support your vocal techniques. Claudia
Freidlander, CPT, part 1.
4. Exercise to improve your core strength- by Mayoclinic staff. Mayo foundation for medical education
and research.
Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013
23
5. Breath holding after breathing of oxygen. F.J. klocke and H. Rahn. Journal of applied physiology,
American physiological society.
6. Peak expiratory flow rate. The Indian journal of pediatrics. Nov-Dec 1994, volume 61, issue 6, page
no. 701 .
7. An investigation of abdominal muscle recruitment for sustained phonation in 25 healthy singers. Ian
MacDonald, John S. Rubin, Ed Blake et all. Journal of voice, volume 26, issue 6, Nov 2012, page nos.
815e.9-815e.16
8. Reduced pulmonary function in wind instrument players. Omer Deniz, Sema Savci, Ergun
Tozkoparan et al. Archives of Medical Research, volume 37, issue 4, May 2006, page nos. 506-517.
9. Respiratory muscle training for singers by using respiratory muscle training device.Do Hyun Nam,
Jan Yol Lim, Chul Min Ahn et al.Yonsei Medical Journal, volume 45, issue 5, 2004, page nos.810
817
10. Study on breathing method for improving singing skills. Tae-seon-Cho Book- Green and smart
technology with sensor application, volume-338, 2012, page nos.372-377
11. Principles and practice of cardiopulmonary physical therapy (3rd edition) – Donna Frownfelter,
Elizabeth Dean.
12. Reliability of test measuring transverses abdominis muscle recruitment with a pressure biofeedback
unit. Katharnia von Garnier et al. Physiotherapy, volume 95, issue 1, March 2009, page nos. 8-14
13. Inefficient muscular stabilization of lumbar spine associated with low back pain; a motor control
evaluation of transverses abdominis muscle. Hodges PW, Richardson CA, 1996, issue 35, page nos.
783-805.
14. Tidy’s physiotherapy –by Staurt Porter. 14th edition.
CORRESPONDING AUTHOR:
*Asst. Professore, Dept. Of Physiotherapy, Pad Dr. D.Y. Patil University, 6th floor, Pad Dr. D.Y. Patil
Medical College Bldg., Sector 5, Nerul, Navi Mumbai.
**Intern, Dept. Of Physiotherapy, Pad Dr. D.Y. Patil University, 6th floor, Pad Dr. D.Y. Patil Medical
College Bldg., Sector 5, Nerul, Navi Mumbai.
***Professore & Director, Dept. Of Physiotherapy, Pad Dr. D.Y. Patil University, 6th floor, Pad Dr. D.Y.
Patil Medical College Bldg., Sector 5, Nerul, Navi Mumbai.
24
AEROBIC CAPACITY, BODY MASS INDEX AND FAT FOLD
MEASUREMENTS OF HEALTHY ATHLETES IN DEHRADUN – A CR OSS
SECTIONAL STUDY
Sharma Chetan, MPT (Sports), Dr. Dar Shahid Mohd., MPT (Orthopedic and Sports)
ABSTRACT
PURPOSE: The Aim of Present study was done to assess the Percent Body fat, Body Mass Index and VO2
Max for the athletes of Dehradun. The study would create a data for athletes in Dehradun involved in various
sporting activities which would catagorised the subject having recommended parameters of fitness.
METHODOLOGY: A survey Study with measurement of Aerobic capacity, Body Mass Index and Percent
Body Fat was done. Total of 96 subjects was included based on the inclusion and exclusion criteria.
Convenience Sampling was used for the selection of participants. Descriptive Statistics has been used for the
analysis of the data. RESULTS: A sample of 96 Athletes with Mean Age (15.634±2.54 years) had a mean
Percent Body Fat 10.537±3.51 percent, mean Body Mass Index 18.654±1.64 kg/m2 and mean VO2 Max is
41.943±6.777 ml/kg/min. CONCLUSION: There was no significant correlation found between VO2 max,
Body Mass Index and Percent Body Fat.
KEY WORDS: Aerobic capacity, Body Mass Index, VO2 Max, Percent Body Fat, 20 m Shuttle Run Test.
INTRODUCTION
Direct measurement of maximum oxygen
uptake (VO2max) is recognized as the best single
index of aerobic fitness, but the test of the direct
measurement of cardiorespiratory endurance
(VO2max) itself is difficult, exhausting and often
hazardous to perform regardless the type of
ergometer used. Since the direct testing procedure
is rather complicated on larger populations, several
indirect running and walking field tests have been
Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013
25
developed. Scientists often calculate VO2max with
indirect protocols. It has been stated that equations
for predicting VO2max indirectly using field tests
are very sensitive to populations tested on.
Therefore, before applying any indirect protocol
for prediction of VO2max, the validity of the test
should be established in a particular population.4
Body mass index (BMI) is used as a
surrogate for percent fat in classifying obesity.
However, there is no established criterion for
percent fat and health risk, and few studies have
examined the validity of Body Mass Index as a
measure of Percent fat. Body Mass Index is used
to classify athletes and young adults as obese.
Consequently, it is critical to understand the
accuracy of Body Mass Index in this populations.1
Body mass index is currently the most frequently
used and widely accepted method to classify
medical risk according to weight status. Body
Mass Index is a useful measure of adiposity in
young and middle-aged athletes.5
Body composition determined from
skinfold measurements correlates well (r = 0.70–
0.90) with body composition determined by hydro
densitometry. The principle behind this technique
is that the amount of subcutaneous fat is
proportional to the total amount of body fat. It is
assumed that close to one third of the total fat is
located subcutaneously. The exact proportion of
subcutaneous-to-total fat varies with sex, age, and
ethnicity. Therefore, regression equations used to
convert sum of skinfolds to percent body fat must
consider these variables for greatest accuracy. To
improve the accuracy of the measurement, it is
recommended that one train with a skilled
technician, use video media that demonstrate
proper technique, participate in workshops, and
increase experience in a supervised practical
environment. The accuracy of predicting percent
fat from skinfolds is approximately ± 3.5%
assuming that appropriate techniques and
equations have been used.1
METHODOLOGY
Design
This is a Cross sectional study. All the
subjects were recruited from the various sports
center from Dehradun.
Sampling
Total of 96 subjects were chosen as per the
inclusion and exclusion criteria, and informed
consent was obtained from all the subjects after the
procedure was explained to them.
Procedure:
20 Meter shuttle run test: The 20 Meter
Shuttle Run Test was administered in a sports field
using the original protocol (Leger and Lambert,
1986) but utilizing a different scoring system
developed by the Human Performance Laboratory
at The Queen's University of Belfast.7 The 20
Meter Shuttle Run test involves running between
two lines set 20 meters apart at a pace dictated by
a cassette recording emitting tones at appropriate
intervals. The test score achieved by the subject is
the number of 20 meter laps completed before the
subject either withdraws voluntarily from the test.
Scoring by aps differs from the "paliers", 6 used in
the original version of the test. The test is made up
of 23 levels where each level lasts approximately
one minute. Each level comprises of a series of
20m shuttle runs where the starting speed is 8.5
km/hr and increases by 0.5km/hr at each level. On
the tape/Compact Disc a single beep indicates the
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26
end of a shuttle and 3 beeps indicates the start of
the next level.
Body Mass Index: The Body Mass Index
is used to assess weight relative to height and is
calculated by dividing body weight in kilograms
by height in meters squared (kg.m-2).1
Skinfold Measurement: Body composition
determined from skin fold measurements.
Seven Site Formula for Men (chest, mid-axillary,
triceps, subscapular, abdomen, Supra iliac, thigh).
Body density = 1.112 - 0.00043499 (sum of seven
skinfolds) + 0.00000055 (sum of seven
skinfolds)2- 0.00028826 (age) [SEE 0.008 or
~3.5% fat).1
RESULTS:
Means and standard deviations of athletes
in Dehradun, predicted VO2max by the 20-m
multi stage shuttle run test, Age, Body mass index
and Percent body fat were presented in the Table
1.
Table 1:- Mean and Standard deviation for Age,
Percent Body fat, Body Mass Index and Vo2 max
in total no. of subjects.
Figure 1: Mean with Standard deviation of Age,
Percent body fat, Body mass index and VO2 max
in total no of subjects.
Table 2: Correlation between Body Mass Index
and VO2 Max as well as Percent Body fat and Vo2
max in total no. of Subjects.
No significant variation was observed (p >
0.05) between the values of Body Mass Index and
VO2max as well as Percent Body Fat and Vo2
max. Correlation was done for comparison
between Percent Body fat and VO2 Max was found
that r = 0.058 which is not significant (p = 0.576)
and another Correlation has been done between
Body Mass Index and VO2 max was found to be r
= -0.037 which is also not significant (p = 0.721),
thus finding not significant between the respective
variables.
DISCUSSION
The Aim of Present study was done to
assess the Percent Body fat, Body Mass Index and
VO2 Max for the athletes of Dehradun. The
athletes were recruited mainly from different types
of sports those who participate in sporting
activities in different colleges and academies. A
sample of 96 Athletes with Mean Age
(15.634±2.54 years) had a mean Percent Body Fat
10.537±3.51 percent, mean Body Mass Index
18.654±1.64 kg/m2 and mean VO2 Max is
41.943±6.777 ml/kg/min. In this study Pearson
Correlation was done for comparison between
Percent Body fat and VO2 Max was found that r =
Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013
27
0.058 which is not significant (p > .05) and
another Correlation has been done between Body
Mass Index and VO2 max was found to be r = -
0.037 which is also not significant (p > .05), thus
finding not significant between the respective
variables.
In the present study it has been found that
Mean Vo2 max for 96 active athletes of age group
of 10-30 years in five different kinds of sports is
(41.943 ml/kg/min), while in a similar study was
done by S. K. VERMA et al. Department of
Human Biology, Punjabi University, Patiala who
found that the mean V02 max in 96 active athletes
age group of 17-25 years was 48.4 ± 5.1 ml/kg/min
with a highest value of 56.4 ml/kg/min and lowest
value of 44.2 ml/kg/min. Which is slightly higher
as compared to V02 max values recorded in the
present study, this probably can be due to the
greater body surface area of athletes in S.K.
Verma’s study where the age group of the subjects
was greater (17-25 years).9 Where as in the present
study the maximum sample obtained was in the
range of 10-20 years because of non-availability of
the athletes in the elder age group. As the age
increases the body surface area increases as is
already proved and the increase in the aerobic
capacity with age is also a well-established fact,4
so our values of less vo2max readings in subjects
of lesser age group than readings of other studies
is quite well understood. Hence forth we
recommend that in future the studies should make
sure that the sample possess the even distribution
of all age groups i.e.… 10-30 years.
As far as Body Mass Index of male
athletes in Dehradun is concerned, the present
study found that the mean of Body Mass Index
was 18.654±1.64 kg/m2. Percent body fat is
10.537±3.51 percentage. In support of present
study Wan Nudri WD et al. from Division of
Human Nutrition, Institute for Medical Research,
Kuala Lumpur, has found mean Body Mass Index
of athletes with age of (23.9±4.2 years) is
(22.9±3.5 kg/m2)10 the probable reason for the
difference between Body Mass Index of both study
is the age. However it was clear that the athletes
who had reduced level of Body Mass Index were
due to lean muscle mass.28 From 5 to 16 years of
age, boy’s relative muscle mass increases from
about 42–54% of body mass.2
A paper review done by American Dietetic
Association, Dietitians of Canada, and the
American College of Sports Medicine stated that
the male athletes with the lowest estimates of body
fat (less than 6%) include middle-distance and
long-distance runners and bodybuilders, whereas
male basketball players, cyclists, gymnasts,
sprinters, jumpers, triathletes, and wrestlers
average between 6% to 15% body fat. Male
athletes involved in power sports such as football,
rugby, and ice and field hockey have slightly more
variable body fat levels 6% to 19%.8 The present
study is done on population of Dehradun, India.
Although, there may be racial differences between
both the populations, it was found that level of
percent body fat had a similarity.
In this study a Correlation between percent
body fat and Vo2max also was done and study
found that the two variables are not significantly
correlated (r=.058, p > .05) . Similarly Body Mass
Index and Vo2max also were found to be
correlated non-significantly (r = -.037, p > .05).
This is in contradiction with other studies done in
the past who have found a positive correlation
between BMI and Percent body fat with VO2
max.10 The reason for non-significant correlation
in present study could be due to the non-
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28
homogeneity of the sample of our study, i.e….in
present study athletes from all the games with
different Body Composition were included, which
could have given a unexpected result.
CONCLUSION:
Study is done to access VO2 max, Body mass
index and Percent body fat in a sample of 96
athletes, found out Mean VO2 max was
41.943±6.777 ml/kg/min, mean Body mass index
was 18.654±1.64 kg/m2 and mean Percent body fat
was 10.537±3.51 percent. There was no significant
correlation was found between Variables which
could have been because of non-homogenous
group.
REFERENCES:
1. Armstrong L, phd, FACSM, Balady G. J., MD, Berry M.J., phd, FACSM. ACSM's guidelines for
exercise testing and prescription. 7thed. New York. Lippincott Williams & Wilkins 2006; p. 64.
2. Armstrong N, Grant R Tomkinson GR, Ekelund Ulf. Aerobic fitness and its relationship to sport,
exercise training and habitual physical activity during youth. Br J Sports Med. 2011; 45:849–858.
doi:10.1136/850 bjsports-2011-090200.
3. Eliakim A, Burke G S, Cooper D M. Fitness, fatness, and the effect of training assessed by magnetic
resonance imaging and skinfold-thickness measurements in healthy adolescent females. Am J Cliii
Nutr. 1997; 66: 223-31.
4. Leger L, Gadoury C et al. Validity of the 20 m shuttle run test with 1 min stages to predict VO2max
in adults. Can J Sport Sci. 1989; 14(1):21-6.
5. Leitzmann MF, Moore sc, Koster a, Harris tb, Park y, et al. (2011) Waist Circumference as Compared
with Body-Mass Index in Predicting Mortality from Specific Causes. Plos One. 2011 April; 6(4):
e18582. Doi:10.1371.
6. Mechelen W.V, Hlobil H, Kemper H.C.G. Validation of two running tests as estimates of maximal
aerobic power in children. European journal of applied physiology and occupational physiology.
1986; 55 (5), 503-506, DOI: 10.1007/BF00421645.
7. Paliczka V.J, Nichols A.K, boreham C.A.G. A multi-stage shuttle runs as a predictor of running
performance and maximal oxygen uptake in adults. Brit.j.sports med. 1987; 21(4): pp. 163-165.
8. The American College of Sports Medicine, The American Dietetic Association, The Dietitians of
Canada. Nutrition and Athletic Performance. Medicine & science in sports & exercise. 2000; 0195-
9131/00/3212-2130/0.
9. Verma S. K, L. S. Sidhu, Kansal D. K. Aerobic work capacity in young sedentary men and Active
athletes in India. Brit. J. Sports Med. 1979; 13: 98-102.
10. Wan Nudri WD, Ismail MN
and Zawiak H.
Anthropometric measurements and body composition of
selected national athletes. Mal J Nutr. 1996; 2: 138-147.
CORRESPONDING AUTHOR:
Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013
29
*M.P.T. (Neurology)., F.N.R., P.G.C.D.E. Health Care Consultant, Bharathidasan Matric Hr Sec School,
Kanchipuram, Tamilnadu, India. & Consultant Physical Therapist, Star Health Care Center, Kanchipuram,
Tamilnadu, India.
**Bachelors in Physiotherapy (India), PG Dip Sci - Exercise Rehabilitation (Clinical Exercise Physiology),
University of Auckland, New Zealand.
30
EFFECTS OF BIMANUAL FUNCTIONAL PRACTICE TRAINING ON
FUNCTIONAL PERFORMANCE OF UPPER EXTREMITY IN CHRONI C
STROKE
Dr Jasmine Anandabai*, Dr Manish Gupta**
ABSTRACT
OBJECTIVE: To study the effects of bimanual functional practice training on functional performance of
upper extremity in chronic stroke. DESIGN: Pre-test and Post test design. SETTING: Inpatient and
rehabilitation hospital. PARTICIPANTS: Patients were randomized to receive bimanual functional practice
(n=15) at 3-4 months post-stroke onset. INTERVENTION: Supervised bimanual training for 50 minutes on 5
days week over 2 weeks using a standardized program. MAIN OUTCOME MEASURES: Upper extremity
outcomes were assessed by Graded Wolf-Motor Function Test (GWMFT) and Fugl-Meyer scale (F.M.S).
RESULTS: Significant differences were found within the group in mean performance time -p=0.002 and
there were significant difference found in functional ability scale (GWMFT-FAS p=0.00, similarly, there were
significant changes in Fugl-Meyer score p=0.00. CONCLUSION: This study suggests that 2 sessions of 25
minutes a day of bilateral training of functionally related tasks is effective for upper limb functional recovery
in chronic stroke patients, regardless of the initial severity of the impairment. Further more, for recovery of
functional motor performance, bimanual practices appears more beneficial. Several other studies have found
benefits of bimanual training: therefore, this approach can be accepted as an upper limb intervention in
stroke on the basis of finding of this study.
KEYWORDS: Stroke, Functional Performance, Bimanual Functional Practice Training
31
INTRODUCTION
Stroke is an acute onset of neurological
dysfunction due to an abnormality in cerebral
circulation with resultant signs and symptoms that
corresponds to involvement of focal areas of the
brain1. This can be due to ischemia (lack of blood
supply) caused by thrombosis or embolism or due
to a hemorrhage. As a result, the affected area of
the brain is unable to function, leading to inability
to move one or more limbs on one side of the
body, inability to understand or formulate speech
or inability to see one side of the visual field. In
the past, stroke was referred to as cerebrovascular
accident or CVA, but the term "stroke" is now
preferred.
The traditional definition of stroke, devised
by the World Health Organization in the 1970s, is
a "neurological deficit of cerebrovascular cause
that persists beyond 24 hours or is interrupted by
death within 24 hours". Strokes can be classified
into two major categories: ischemic and
hemorrhagic. Ischemia is due to interruption of the
blood supply, while hemorrhage is due to rupture
of a blood vessel or an abnormal vascular
structure. 80% of strokes are due to ischemia; the
remainders are due to hemorrhage. Some
hemorrhages develop inside areas of ischemia
("hemorrhagic transformation"). In an ischemic
stroke, blood supply to part of the brain is
decreased, leading to dysfunction of the brain
tissue in that area. There are four reasons why this
might happen: thrombosis (obstruction of a blood
vessel by a blood clot forming locally), embolism
(idem due to an embolus from elsewhere in the
body, see below), systemic hypo perfusion
(general decrease in blood supply, e.g. in shock)
and venous thrombosis. Stroke without an obvious
explanation is termed "cryptogenic" (of unknown
origin); this constitutes 30-40% of all ischemic
strokes.
Ischemic: Ischemic stroke occurs due to a loss
of blood supply to part of the brain, initiating the
ischemic cascade. Brain tissue ceases to function if
deprived of oxygen for more than 60 to 90 seconds
and after a few hours will suffer irreversible injury
possibly leading to death of the tissue, i.e.,
infarction.
Hemorrhagic: Hemorrhagic strokes result in
tissue injury by causing compression of tissue
from an expanding hematoma or hematomas. This
can distort and injure tissue. In addition, the
pressure may lead to a loss of blood supply to
affected tissue with resulting infarction.
Epidemiology: Stroke is a major global health
problem. It is the third most common cause of
death in world and risk factors for stroke onset are
high blood pressure, smoking, diabetes, heart
failure, carotid artery stenosis and hyperlipidemia
(SBU 1992; Gresham et al. 1995). 3
Approximately 85% of all stroke cases are
ischemic, and most ischemic strokes affect one of
the cerebral hemispheres by occlusion of the
middle cerebral artery (MCA). In the acute stage,
mechanisms such as oxygen depletion, necrosis,
brain edema, excitotoxicity and inflammatory
processes are at play. After the acute stage there is
a phase of regeneration with neuronal plasticity
and (partial) functional recovery (Dahlquist
2003).4
The effectiveness is based on
neurodevelopment techniques, repetitive unilateral
or bilateral training techniques; sensoriomotor
training or constraint induced movement therapy
has been evaluated on motor performance of the
affected arm of subjects with stroke. The
Constraint induced movement therapy concept has
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32
been derived from basic research with monkeys
and consists of a family of techniques, i.e.,
constraining movements of the less affected arm
and intensively training of the more affected arm
(Taub et al. 1993; Taub et al. 1999; Morris and
Taub 2001). 4
Bilateral training activities may increase the
activity of the affected hemisphere and decrease
the activity of unaffected hemisphere providing a
balancing effect between hemispheric
cortocomotorneuron exitibility. 5
The practice of bilateral symmetrical
movements may allow the activation of the intact
hemisphere to facilitate the activation of the
damaged hemisphere leading to improve
movement control of impaired limb promoting
neural plasticity. Bimanual practice is getting both
hands to work co-operatively to hold and
manipulate an object using each hand to perform
different actions.
Thus the objective of this study is to establish
the efficacy of bimanual functional practice on
functional performance of upper extremity in
chronic stroke.
METHODOLOGY
A total of 15 subjects (12 males and 3
females), at O.P.D. of various hospitals, were
included in the study. They were given bimanual
practice intervention for 5 days a week for 2
weeks. Each treatment session will be of 1 hour.
Inclusion Criteria:
1. All Participants suffering from stoke for the
first time.
2. Onset from 3-9 months
3. Age group 40-60 yrs.
4. Most component of movement present in
affected extremity but impairment of
function relative to non-affected side (at least
100 of wrist extension and at least 100 of
active extension of each metacarpophalengeal
joint and interphalengeal joint of all digits.
5. No multiple infarctions.
6. Intact cognitive functions
7. Patients with right hand dominance with
affected left Hemispheres.
Exclusion Criteria:
1. Insufficient stamina to participate.
2. Other neurological disorders
3. Previous participation in other pharmalogical
or Physical intervention studies.
4. Any severe contractures and deformity in
upper Extremity.
5. Aphasia with inability to follow 2 step
commands.
On the first visit a complete neurological
assessment was done. Subjects found suitable for
participants in the study as per the inclusion and
exclusion criteria were requested to sign the
consent form. A detailed subjective examination
was taken regarding type, side, duration,
occurrence of stroke, handedness and motor
functions.
All the selected subjects were informed in
detail about the type and nature of the study and
asked to sign the informed consent.
After taking down the demographic data the
measurement of functional performance were
assessed by Fugl- Mayer assessment scale and
Graded Wolf Motor Function test.
Participants were trained for bimanual
activity.
Participants were encouraged to do the
bimanual practices for 25 minutes with 10 minutes
Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013
33
rest periods.
The total time period of the bimanual practice
was one hour, which was divided into two training
sessions (25*2=50 min) and one rest period of 10
minutes.
Participants were trained for following
bimanual task practices (15).
• Pouring of water from one cup to another
cup with arm held up.
• Using the telephone (one hand to hold
receiver and another to dial the number
• Rolling up a towel
• Unscrewing a jar.
• Turning the key in lock
Each participants were taught about
individually and Sitting at the chair comfortably in
front of the table.
1. To ask the patient to hold the one cup with
one hand (non-affected) which was initially filled
with water and asked to hold the cup with other
hand (affected) and both hands held up the table.
Instruct the patient to pour the water first from
non-affected hand to affected hand and then
affected hand to non-affected. This task was
performed for 5 minutes daily in two sessions.
2. To ask the patients to hold the receiver with
one hand (non-affected) and the numbers with
another hand (affected) again this task performed
alternately hold the receiver with affected hand
and dials the numbers with affected hand.
3. Initially fold the towel lengthwise and asked
the patient to roll the towel with both hands up to
the towel end.
4. Asked the patients to hold the jar with non-
affected and practiced to open the jar or move the
cup of the jar to clockwise and anticlockwise. This
task was practiced for 5 minutes in two sessions.
5. Asked the patient to hold the lock with non-
affected hand and open the lock or move the key in
the lock clockwise and anticlockwise for 5 minutes
daily in two sessions.
RESULTS
The results in table 5.4 show that MPT of
Wolf-motor Function Scale after 2 weeks of
bilateral training program was significantly less.
Similarly FAS score improved significantly after a
2 weeks training program.
Table-1 Group Analysis
The results showed that there was significant
difference in the bilateral arm training group, both
pre intervention and again after 2 weeks of
training.
DISCUSSION
The study compared the effects of bilateral
upper limb-task training on upper limb motor
functions during post stroke rehabilitation. The
result of this study showed that there was a
significant improvement in functional performance
of upper extremity on G.W.M.F.T. and Fugl-
Meyer scale in chronic stroke patients after 2
weeks of bimanual functional practice.
The result of the study showed that there was
significant difference in bimanual Pre and Post
practice group on GWMFT (Pre MPT: p=0.70 &
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34
Post MPT: p=0.75 and Pre FAS: p=0.32 & Post
FAS: p=0.312) and Fugl-Meyer score. (Pre:
p=0.519 and Post: p=0.43)
Participants of bimanual practice group
showed a decrease in performance time (p=0.002)
and increase on functional ability score (p=0.00)
and showed highly significant improvement on
motor functional performance of Fugl-Meyer scale
(p=0.00).The mean time to perform 15 tasks in
GWMFT was (17.13+4.60) which decreased after
2 weeks of bimanual practice training
(15.80+5.53) and the functional ability score
(1.75+0.46) improved after training
(2.05+0.57).The result showed that 2 weeks of
bimanual training improved motor functional
performance on Fugl-Meyer scale (42.87+5.25).
The result showed that 2 weeks of bimanual
training improves motor functional performance
on Fugl-Meyer scale (44.53+6.20).
The result of the study suggested that, training
involving the practice of actions bilaterally and
simultaneously is effective in promoting recovery
of upper limb motor function in chronic stroke
patients. Of particular importance was significant
increase in participants of the bilateral training
group in functional ability of the upper limb,
demonstrating a generalization from the training of
a specific movement to general upper limb
function. Individuals receiving bilateral training
showed improvements in the time to complete the
graded wolf motor function test (GWMFT)
movement with the impaired limb 15.
In the study, participants were trained in
complex multi joint functionally relevant tasks,
whereas other bilateral training studies have
involved protocols using simple repetitive
movements with electric stimulation 48 or auditory
cueing 35, 36. Furthermore visualizing and
processing information from the non-paretic limb,
while simultaneously attempting to perform new,
progressively changing, relatively complex precise
motor goals with both arms may have provided a
dual-task challenge greater than in other studies.
The effectiveness of bilateral movement
training in promoting stroke recovery is also likely
to depend on the extent of damage sustained to
direct corticospinal pathways58. While bilateral
movements may also help recruit secondary motor
areas in both hemispheres, recovery promoted by
these areas will be less than that obtained through
direct corticospinal projections 58, 59. This can be
explained by the changes in the functional ability
of impaired limb as evidenced by GWMFT scores
and in motor performance by Fugl-Meyer score in
the patient group used in the study. Recent
research has shown that lesion location greatly
influences the pattern of motor cortex excitability
observed 60.
Intervention timing may have influenced
outcomes. The study showed significant effects of
bilateral training in chronic stroke participants,
whereas some studies showed no effects of
bilateral training in patients with acute stroke 34.
Stroke appears to alter normal transcallosal
inhibition resulting in increased intact hemisphere
excitability during hemiparetic arm movement that
may be inhibitory in nature, thus suppressing
output from the damaged hemisphere 23.
Depending on the lesion site and size, these over
activation appear transient, and more normal
contralateral activation pattern resume over time 49. Identical motor commands generated in each
hemisphere during bilateral movement may
modulate transcallosal inhibition, balancing stroke
related interhemspheric over activity and
facilitating output from the damage hemisphere as
Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013
35
well as from normally inhibited ipsilateral pathway
of the undamaged hemisphere to augment
movement of the paretic arm 50.
there is a strong neurophysiological evidence
to suggest that when the impaired and non
impaired arms are moved symmetrically, crossed
facilitatory drive from the intact hemisphere will
be produced increase excitability in homologous
motor pathways in the impaired limb 50, 51.
Additionally, cortical damage from stroke
produces hyperexcitability of the contralesional
M1 52 leading to abnormally high levels of
transcollasal inhibition (TCI) on the legend
hemisphere, thereby further impairing motor
performance of the paretic hand 53. There is recent
evidence of improved affected hand performance
in chronic stroke patients from reducing the
abnormal inhibitory drive to the ipsilesional
hemisphere 54, 55. Further more, balanced
interhemspheric interactions appear necessary for
normal voluntary movements 56 and the restitution
of the normal balance between the two
hemispheres has been linked to better recovery
following stroke 57. It has been hypothesized that
practicing by lateral symmetrical movements may
facilitate motor output from the ipsilesional
hemisphere by normalizing (TCI) influences.
Interestingly, in the subset of patients assessed
with wolf motor function test and Fugl-Meyer
scale in the study the bilateral trained patients
exhibiting the largest increase in functional ability.
In addition, bilateral training may promote
increased involvement of pathways not
investigated in the present study such as spared
corticopropriospinal pathways 50.
The chronic nature of stroke might have
allowed the plastic nature of brain to adjust to the
various levels of tasks to be performed
bimanually.Initially, just after stroke, bimanual
movement enhanced activation in the primary
motor cortex M1 of the affected hemisphere did
not differ between unimanual paretic hand and
bimanual movement 14.
The frequency and duration of the program
may not have been optimal. One may ask whether
20 25-minutes sessions devoted to the bimanual
task are sufficient to trigger brain reorganization
and to observe a change. This scheduled was based
on practical reason and although it is similar to
that used in previous study 34, 61,
The study does not suggest the training
characteristics, such as the nature of the tasks and
strength of inter limb coupling required for effects
, may influenced outcomes: therefore future work
should examined the optimal timing, dose and
training tasks that might optimize the already
known facilitatory effects of interlimb coupling.
CONCLUSION
This study suggest that 2 sessions of 25
minutes a day of bilateral training of functionally
related tasks is effective for upper limb functional
recovery in chronic stroke patients, regardless of
the initial severity of the impairment.
Furthermore, for recovery of functional motor
performance, bilateral training appears beneficial.
Several other studies have found benefits of
bimanual training: therefore, this approach can be
accepted as an upper limb intervention in stroke on
the basis of finding this study.
The study does not suggest the training
characteristics, such as the nature of the tasks and
strength of inter limb coupling required for effects,
may influenced outcomes: therefore future work
should examine the optimal timing, dose and
training tasks that might optimize the already
known facilitatory effects of interlimb coupling.
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36
Thus, null-hypothesis proved.
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CORRESPONDING AUTHOR:
*PhD Research Scholar, Singhania University
**Consultant Orthopaedics, Kapoor Medical Center
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40
A COMPARISON STUDY ON PHYSICAL IMPAIRMENTS AND
FUNCTIONAL LIMITATIONS OF PATIENTS: 1 YEAR AFTER TO TAL
KNEE ARTHROPLASTY VERSUS CONTROL SUBJECTS
Amit Murli Patel*
ABSTRACT
BACK GROUND AND PURPOSE: The purpose of this study was to examine the physical impairments and functional limitations of individuals with total knee arthroplasty (TKA), as compared with individuals with no diagnosed knee disease (control subjects). Subiects. Forty-nine individuals 1 year following TKA (30 women, 19 men) and 40 age- and gender-matched control subjects (28 women, 26 men) were assessed. METHODS: Walking speed, stair climbing ability, knee torque (in newton meters), and total work performed during 15 repeated contractions were evaluated. RESULTS: Walking speeds for men with TKA were 13% and 17% slower at normal and fast speeds, respectively. Their stair climbing ability was even more compromised (51 % slower). Walking speeds for women with TKA were 17% and 18% slower at normal and fast speeds, respectively. Similarly, their stair-climbing time was more compromised (43% slower). Men with TKA were 37% to 39% weaker and performed 36% to 37% less total work of their knee extensors compared with the control subjects. Similarly, women with TKA had knee extensor strength deficits of 28% to 29% and performed 24% less total work. CONCLUSION AND DISCUSSION: One year after TKA, marked physical impairments and functional limitations persisted.
KEY WORDS: Total Knee Arthroplasty, Physical Impairment, Knee osteoarthritis, Knee Strength
INTRODUCTION
In India and in other industrialized nations,
the high prevalence of osteoarthritis (OA of the
knee 1-3 and OA's severe impact on disability have
been well documented4. When conservative
Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013
41
management is ineffective, the surgical treatment
of choice for individuals with severe, end-stage
OA is often total knee arthroplasty (TKA).
Previous research evaluating surgical success
following TKA11-12 focused on either end of the
disability spectrum (impairment-disability).We
believe that a complete description of treatment
outcome requires measures across all levels (i.e,
pathology, impairment, functional limitations, and
disability) of Nagi's model of disablement5.The
pathophysiology of OA of the knee6 and the
effects of alternative surgical interventions have
been investigated7-8. Isolated measurements of
impairment, including measurements of pain and
knee range of motion (ROM), have frequently
been made9. The current trend is to evaluate the
effectiveness of surgical interventions using
patient-reported quality of life measures10-12.
Extensive research regarding disability has led to
an appreciation of the gains expected in patient of
reported quality of life following TKA11.What is
not well described in the literature is the degree of
physical impairment and functional limitation in
individuals following TKA compared with
individuals without knee disease.
Kroll and colleagues13 quantified functional
limitations of male and female patients
preoperatively and at 5 and 13 months following
TKA. They noted a reduced walking speed (22%-
16%) in patients with TKA relative to that of older
men with no diagnosed knee disease. Berman et
all14 compared knee flexor (hamstring) muscle
function between limbs with TKA and limbs
without TKA. Their results suggest that maximal
recovery of hamstring muscle peak torque occurs
by 7 to 12 months postsurgery. It may not be
appropriate, however, to use the side without
surgery for comparison because bilateral OA or
reduced activity consequent to OA and the TKA
may also impair function of the side without
surgery. Jevsevar et al13 compared men and
women who had undergone TKA 1 or more years
previously with a control group of subjects with no
diagnosed knee disease and found that the subjects
with TKA had deficits in angular velocity during
the stance phase while performing activities of
daily living, including walking and stair climbing.
There is a need to document the persistent
physical impairments and functional limitations in
men and women following TKA. The direct goals
of physical therapy are often related to function.
The purpose of our study was to examine the
physical impairments (knee ROM, muscle torque,
and total work) and functional limitations (walking
and stair climbing) of individuals 1 year after
TKA, as compared with of age and Gender
matched individuals with no diagnosed knee
disease. We considered the peak torque (in newton
meters) developed during five maximal
contractions to be an indication of muscle strength.
We considered the total work (in joules)
performed during 15 concentric contractions at
angular velocities of 90˙ and 120˙/s to be an
indicator of Isokinetic knee extensor and flexor
endurance.
Method :
Subjects
The subjects with TKA were 49 consecutive,
consenting individuals (30 women, 19 men) who
had undergone TKA at a single tertiary care
orthopedic hospital. All individuals were assessed
approximately 1 year after surgery (X= 12.6
months, SD= 1.5, range= 11-17). Eight of these
individuals had bilateral knee replacements. Fifty
four similarly aged, control subjects (28 women,
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42
26 men) were recruited from the community
through Patients relatives, working individuals etc.
The control subjects were free of any known knee
pathology and reported no functional limitations
during walking or stair climbing. Control subjects
were matched to patients with TKA based on
gender and age (± 2 years). Written informed
consent was obtained from each subject prior to
clinical testing.
Procedure
Standardized methods for measuring weight
(wt) , height (ht), and girths at the waist and the
hip16 were used. Chum lea et al17 reported a
technical error of measurement of waist girth of
0.48 cm in elderly men and of 1.15 cm in elderly
women. Malina et all8 reported a technical error of
measurement of hip girth of 1.23 cm for
intrameasurer errors. M'ilmore and Behnke19
reported a correlation of 0.99 between
measurements obtained 1 day apart in young male
subjects. Body mass index (BMI : Wt /ht2) and
waist-to-hip ratios (WHR : waist girth/hip girth)
were calculated from the measurements.
Percentage of body fat was estimated from
measurements of body reactance and resistance
obtained with a bioelectric impedance device (BIA
101 Body Composition Analyzer). Muscle volume
of the thigh was estimated from anthropometric
measurements using the method of Jones and
Pearson.20
Knee active range of motion (AROM) was
measured bilaterally, to the nearest degree, using a
goniometer. It is generally reported21-23 that the
reliability of goniometric measurements improves
when the assessment is performed by the same
individual, who uses the same measurement tool
with a standard test position and protocol. In our
study, the same physical therapist using the same
goniometer assessed knee ROM. Subjects lay on a
plinth in the supine position with the knee to be
measured maximally flexed and the foot flat on the
plinth. Specifically, as described by Norkin and
White24 the fulcrum of the goniometer was aligned
with the lateral midline of the femur using the
greater trochanter for reference. Finally, the distal
arm of the goniometer was aligned with the lateral
midline of the fibula using the lateral malleolus for
reference. Goniometer alignment for measuring
knee extension was identical. While in the supine
position, the knee was fully extended and a 10.2
cm (4 inch) rolled towel was placed under the
ankle of the lower extremity to be assessed.
Subjects were asked to maximally straighten their
knee, and the measurement was recorded.
There was no difference in height between the
groups. The subjects with TKA, however, were
heavier, with higher BMI scores and greater
percentages of body fat, than the age- and gender-
matched control subjects (Table 1). Despite a
difference in AROM of knee flexion between
groups, all Individuals with TKA had a knee
AROM of ≥ 90 degrees of flexion, which is
adequate for everyday function. Similarly, subjects
with TKA had an extension loss of ≤ 10 degrees,
although the men showed a difference between
groups in extension. Estimated thigh muscle
volume did not differ between groups for the men.
Women with TKA had a higher estimated muscle
volume value than the women in the control group
had (Table 2).
Concentric isokinetic knee torque and total
work were evaluated on both lower extremities
using a LIDO Active Isokinetic dynamometer.
Subjects with one TKA were tested so that the
limb that did not undergo surgery was tested first.
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43
This limb was tested first to limit apprehension
that would interfere with testing. For all other
subjects, the choice of limb to be tested first was
determined by convenience. All tests were
performed while the subjects were in a seated
position with the hips flexed to approximately 80
degrees. The dynamometer was preset, using
software controls, to evaluate torque (peak torque
(developed during five voluntary maximal
contractions) through a preset knee range of
motion from 20 ± 2 to 90 ± 2 degrees of flexion in
the sagittal plane. The manufacturer of the LIDO
Active system claims that the device is self-
calibrating, and we did not test this claim. Prior to
each test session, the device is supposed to
compensate for gravity by weighing the patient's
limb through the preset range of motion at an
angular velocity of 5˙/s. We did not check whether
these determinations were correct. The validity
and reliability of measurements obtained with the
LIDO Active isokinetic system have previously
been reported by Patterson and Spivey 25
After the subjects practiced bending and
straightening their knee for two to three
repetitions, they were instructed to "bend and
straighten your knee as hard and as fast as you
can" to elicit five continuous maximal voluntary
contractions of the knee extensors and flexors.
Verbal encouragement was standardized by
repeating the same phrase (ie, "kick up, pull down,
kick up, pull down; work as hard and as fast as you
can") during all isokinetic tests. Torque curves
were accepted only when the coefficient of
variation for the five repetitions was less than
10%. Mean peak torque (in newton-meters) was
calculated as the average of the highest torque
values for the five repetitions. Thus, the mean peak
torque recorded during five concentric
contractions at angular velocities of 90˙ and 120˙/s
was used as an indicator of muscle strength of the
knee extensors and flexors.
Table 1
Physical Characteristics and Activity Level of Study Participants by Group and Gender
Variable TKA Group (n=49) Control Group (n=54)
Female (n = 30) Male (n = 19) Female (n = 28) Male (n = 26)
Physical
characteristics
Age (y) 61.3 ± 1.3 66.4 ± 1.7 61.9 ± 1.1 63.6 ± 1.4
Weight (kg) 76.0 ± 2.9 89.1 ± 3.9 64.2 ± 2.6 76.4 ± 1.8
Height (cm) 160.8 ± 1.9 170.3 ± 1.8 158.3 ± 2.1 171.5 ± 1.3
WHR 0.81 ± 0.2 0.93 ± 0.01 0.77 ± 0.01 0.93 ± 0.008
BMI (kg/m2) 29.5 ± 1.3 30.9 ± 1.4 25.2 ± 0.91 25.9 ± 0.45
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44
Percentage of body
fat 37.8 ± 2 25.3 ± 2 31.3 ± 2 21.2 ± 1
Knee active range
of motion
Flexion 114 ± 4.65 110 ± 3.74 143 ± 1.54 142 ± 1.16
Extension - 1 ± 1.43 - 0.4 ± 1.18 - 7 ± 1.37 - 6 ± 0.56
Total score on
physical activity
Questionnaire for
elderly people
23.6 ± 3.71 15.3 ± 2.23 18.2 ± 2.43 19.5 ± 1.56
Table 2
Muscle Thigh Volume and Cross-sectional Area of Study Participants by Group and Gender
Variable TKA Group (n=49) Control Group (n=54)
Female (n = 30) Male (n = 19) Female (n = 28) Male (n = 26)
Thigh muscle
volume (cm3)
Limb with TKA 3413.7 ± 119.8 3921.3 ± 159.9 ……….. ………..
Limb without
TKA 3453.7 ± 217.2 3979.2 ± 200.2 2852.7 ± 155.0 4020.0 ± 199.3
Thigh Muscle
Cross-sectional
area (cm2)
Limb with TKA 13.1 ± 0.4 13.9 ± 0.4 ……….. ………..
Limb without
TKA 12.7 ± 0.2 13.3 ± 0.4 11.7 ± 0.3 13.5 ± 0.2
Table 3
Knee Muscle Peak Torque (in Newton-meters) for Concentric lsokinetic Knee Extension and Flexion at an
Angular Velocity of 90˙/s
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45
Muscle group TKA Group (n=49) Control Group (n=54)
Female (n = 30) Male (n = 19) Female (n = 28) Male (n = 26)
Knee extensors
Limb with TKA 44.8 ± 7.5 69.5 ± 8.7 ….. …..
Limb without TKA 46.3 ± 8.1 82.6 ± 13.0 63.0 ± 3.5 113.6 ± 6.4
Knee flexors
Limb with TKA 26.3 ± 6.9 40.0 ± 6.3 ….. …..
Limb without TKA 31.7 ± 5.0 51.9 ± 6.8 36.0 ± 1.7 61.4 ± 2.3
RESULT
Angular velocity of 120˙/s. Compared with
the angular velocity of 90˙/s, mean peak torque
values were lower at the faster speed in all subjects
except the women with TKA. For these
individuals, the mean peak torques were slightly
higher for both muscle groups (extensors and
flexors) on the side without the TKA and for the
knee flexors on the side with the TKA at 120˙/s
compared with their values at 90˙/s.
When assessed at the angular velocity of
120˙/s, knee peak torque of the women with TKA
improved relative to that of the female control
subjects. For example, their limb with the TKA
had achieved extensor and flexor mean peak
torques of 72% to 85%, respectively, of the values
of the female control subjects. In the male subjects
with TKA, the decrement in mean peak torque
relative to that of the control subjects was
markedly greater at 120˙/s than at 90˙/s. At the
faster angular velocity, extensor and flexor mean
peak torques were just 63% to 65% of those of the
male control subjects. At the angular velocity of
120˙/s, knee peak torque torque of the limb with
the TKA of all individuals who had undergone
surgery was diminished when compared with that
of the control subjects (Table 4).
Knee Total Work
Angular velocity of at 90˙/s. Deficits in knee
extensor and flexor concentric peak torque and
total work were still present 1 year
postoperatively, not only in the limb with the TKA
but in the limb without the TKA of individuals
who had undergone surgery.
On average, total work of the extensors and
flexors of the subjects with TKA was 76% to 73%,
respectively, of the values for the control subjects.
Extensor endurance performance, measured as the
total work of the limb without the TKA in women
who had undergone surgery, was assessed to be
18% less than in the control subjects. Compared
with the control subjects, the performance of the
male subjects with TKA on muscular endurance
testing was generally poorer than on peak torque
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46
testing.
The total work of the extensors and flexors at
90˙/s accomplished by the male subjects with TKA
was only 64% and 55%, respectively, of that of the
control subjects (Table 5).
Angular velocity of 120˙/s. As expected, less
work was produced at the faster angular velocity
of 120°/s compared with the angular velocity of
90˙/s. This pattern was evident across both genders
and groups. Similar to patterns at the slower
angular velocity of 90˙/s, deficits in total work at
120˙/s during 15 maximum repetitions were
evident in the female subjects with TKA.
Specifically, they achieved 76% and 74% of the
extensor and flexor work, respectively, of that
achieved by the female control subjects. Extensor
and flexor total work decrements were less in the
limb without the TKA (87% and 90%,
respectively) of the subjects who had undergone
surgery compared with the control subjects. Male
subjects who had undergone surgery produced
similarly low extensor and flexor total work values
(63% and 57%, respectively) in the limb with the
TKA compared to the male control subjects (Table
6).
Self- Paced Walking
Individuals with TKA achieved over 80% of
the normal and fast walking speeds of their age
and gender matched counterparts 1 year after
surgery (Table 7). Ratings of perceived exertion
and heart rates were similar between the groups,
despite the slower walking speeds at both normal
and fast selected paces in the subjects with TKA.
A perceived exertion rating of 2, anchored by the
expression "slight" on the Borg Scale, was
frequently reported by the subjects with TKA.
Persistent knee pain was reported by the subjects
with TKA following fast walking. Mean ( ± SD)
pain scores were 0.8 ± 0.98 for the men with TKA
and 1.8 ± 2.69 for the women with TKA, where 0
represents "no pain" and 10 represents "maximal
pain." These scores were both statistically
significant (P ≤ .02) and clinically significant
compared with those of the control group.
Stair-Climbing Performance
Both women and men with TKA took more
than twice as long to ascend and descend a flight
of 10 stairs than it took the control subjects (Table
8). Although both men and women performed at a
slower pace, the women with TKA reported a
greater perceived effort and pain in completing the
stair-climbing task. Although all subjects were
instructed to try to ascend and descend the stairs
without using a handrail, six subjects with TKA
(including one subject with bilateral TKA)
required this assistance. All except eight subjects
with TKA (including two subjects with bilateral
TKA) used a reciprocal stepping pattern. One
individual declined performing this task due to
fatigue.
Physical Activity
The subjects with TKA did not differ from the
control subjects in their reported total level of
physical activity, as measured ( X ± SEM) using
the physical activity questionnaire for elderly
people30 (19 ± 2.2 versus 19 ± 1.4, respectively).
Large standard deviations for all groups indicate
the diverse physical activity habits of our study
participants (Table. 1).
Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013
47
Table 4
Knee Muscle Peak Torque (in Newton-meters) for Concentric lsokinetic Knee Extension and Flexion at an
Angular Velocity of 120˙/s
Muscle group TKA Group (n=49) Control Group (n=54)
Female (n = 30) Male (n = 19) Female (n = 28) Male (n = 26)
Knee extensors
Limb with TKA 42.6 ± 6.0 66.4 ±6.9 ….. …..
Limb without TKA 48.8 ± 8.2 77.8 ± 10.4 59.0 ± 2.3 105.2 ±5.7
Knee flexors
Limb with TKA 30.2 ± 6.0 40.3 ± 4.7 ….. …..
Limb without TKA 32.3 ± 4.9 48.9 ± 4.8 35.7 ± 1.5 62.0 ±2.8
Table 5
Total Work (in Joules) for Concentric lsokinetic Knee Extensors and Flexors at an Angular Velocity of 90˙/s
Muscle group TKA Group (n=49) Control Group (n=54)
Female (n = 30) Male (n = 19) Female (n = 28) Male (n = 26)
Knee extensors
Limb with TKA 621.8 ± 87.3 892.8 ± 90.7 ….. …..
Limb without TKA 666.8 ± 112.2 1043.6 ± 133.5 816.8 ± 28.6 1397.4 ± 73.0
Knee flexors
Limb with TKA 350.8 ± 84.7 470.9 ± 57.8 ….. …..
Limb without TKA 430.0 ± 67.5 678.6 ± 60.0 482.5 ± 19.8 849.4 ± 31.4
Table 6
Total Work (in Joules) for Concentric lsokinetic Knee Extensors and Flexors at an Angular Velocity of 120˙/s
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Muscle group TKA Group (n=49) Control Group (n=54)
Female (n = 30) Male (n = 19) Female (n = 28) Male (n = 26)
Knee extensors
Limb with TKA 523.3 ± 75.8 810.1 ± 66.7 ….. …..
Limb without
TKA 600.2 ± 112.1 934.4 ± 124.9
Knee flexors
Limb with TKA 331.2 ± 64.8 440.0 ± 42.9 ….. …..
Limb without
TKA 401.8 ± 70.5 563.4 ± 47.6 447.9 ± 23.5 766.1 ± 32.4
Table 7
Performance for the 160-m Walk Test at Normal and Fast Self-paced Walking Speeds
Variable TKA Group (n=49) Control Group (n=54)
Female (n = 30) Male (n = 19) Female (n = 28) Male (n = 26)
Normal self paced walking speed
Speed (m/s) 1.17 ±0.05 1.31 ± 0.05 1.38 ± 0.03 1.51 ± 0.03
Pain ( 0 – 10 ) 1.0 ± 0.7 0.5 ± 0.3 0.0 ± 0.0 0.0 ± 0.0
RPE ( 0 – 10 ) 1.2 ± 0.4 2.2 ± 0.4 0.5 ± 0.2 0.7 ± 0.2
Fast self paced walking speed
Speed (m/s) 1.36 ± 0.1 1.53 ± 0.06 1.65 ± 0.03 1.84 ± 0.03
Pain ( 0 – 10 ) 1.6 ± 0.7 0.8 ± 0.4 0.0 ± 0.0 0.0 ± 0.0
RPE ( 0 – 10 ) 1.6 ± 0.4 2.6 ± 0.5 1.6 ± 0.2 1.8 ± 0.2
Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013
49
Table 8
Group x Gender Performance While Ascending and Descending One Flight of 10 Steps
Variable TKA Group (n=49) Control Group (n=54)
Female (n = 30) Male (n = 19) Female (n = 28) Male (n = 26)
Stair time (s) 31.10 ± 0.49 23.33 ± 2.3 12.45 ± 0.47 11.81 ± 0.31
Pain ( 0 – 10 ) 1.9 ± 1.0 0.9 ± 0.6 0.0 ± 0.0 0.0 ± 0.0
RPE ( 0 – 10 ) 2.4 ± 0.6 2.2 ± 0.4 0.4 ± 0.2 1.2 ± 0.5
DISCUSSION AND CONCLUSIONS
Our findings indicate that marked
impairments and some functional limitations
persist in individuals even 1 year following TKA.
The relative absence of pain but elevated rating of
perceived exertion and heart rate responses to
physical activity and decreased concentric muscle
strength suggest that physical deconditioning may
strongly contribute to the decreased function in
these individuals. Alternative explanations for the
observations include differences in body
composition or biomechanical efficiency of
walking between the subjects with TKA and the
control subjects. The subjects with TKA were
heavier (12-13 kg) and had a higher percentage of
body fat (4%-6%) compared with their age- and
gender-matched control subjects. Osteoarthritis is
typically associated with increased body fat even
in earlier stages of the disease33 but our study
provides evidence that differences persist even 1
year after TKA. The values for BMI obtained for
the subjects with TKA are associated with
increased risk of morbidity and mortality16. One of
the limitations of our study is that the subjects with
TKA had increased body fat compared with the
control subjects. We are unable, therefore, to
delineate the effects of obesity from those of TKA
on function.
Volunteers are known to have better health
and higher functional abilities than the general
population.34 The results of both the subjects with
TKA and the control subjects may have been
influenced by this volunteer effect. The body
composition measurements (weight, BMI),
although different between the subjects with TKA
and the control subjects, were similar to age and
gender matched normative values from a Canadian
survey.16 Walking speed was within approximately
1 standard deviation of age-predicted values for
men and wornen at both self-selected paces35
These comparisons suggest that our control sample
was representative of healthy older people.
Although no survey data on individuals with
TKA are currently available, data from other
studies suggest that our subjects with TKA may
have had higher than average functional levels.
Berman et all4 reported a normal walking speed for
men and women who were tested 2 to 3 years after
TKA (0.90 m/s) that was slower than our mean
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value (1.25 m/s) at the normal walking speed.
Mattsson and colleagues36 reported a maximal
walking speed over 4 minutes of 1.25 m/s for 12
men and 16 women who were tested 1 year after
TKA. Free walking speed 1 year after TKA for1 7
men and 11 women was 1.07 m/s in the study by
Kroll et al13 The higher walking speed observed
for our subjects suggests that our estimates of the
degree of impairment 1 year after TKA may be
conservative relative to other individuals who have
TKA surgery.
Osteoarthritis is associated with altered gait
mechanics37 Previous studies38,39 however, suggest
that biomechanical differences in gait between
subjects with TKA and subjects with no diagnosed
knee pathology are minor. Our observation of only
minor deficits in ROM supports those
observations.
Reduced physical activity may be both a
cause and a consequence of physical impairment
and functional limitation. Pain associated with OA
limits physical activity, and surgical intervention
that decreases pain should allow resumption of
normal activities. If reduced physical activity has
become habitual, however, this might contribute to
continuing obesity and deficits in physical
capacity. Our findings indicate no differences in
total physical activity scores between subjects with
TKA and control subjects. The physical activity
questionnaire for elderly people30 used in our study
divides activities into low, medium, and high
categories. It was evident that few of either the
control subjects or the subjects with TKA were
active in more physically demanding activities (ie,
sporting activities). Only 38% of the subjects with
TKA and only 47% of the control subjects
reported involvement in any sporting activity
during the previous year. Spontaneous resumption
of low intensity activities did not appear to be an
adequate stimulus to rebuild muscle torque, total
work, or aerobic condition, nor was the resumption
of active living adequate to reduce obesity.
Impairment in muscle function was evident from
the reductions in mean peak torque and total work
for knee flexion and extension. Force generation is
expected to decrease as the speed of movement
increase40 but this decrease was not observed in
our female subjects with TKA. We also expected
that functional deficits would relate to the degree
of muscle atrophy assessed by anthropometry. We
found no such relationship. No reduction in muscle
volume was evident in the male subjects with TKA
when compared with the control subjects, and the
female subjects with TKA had a greater muscle
volume and estimated cross-sectional area
compared with the control subjects (Table 2).
Clinical examination of the study participants
ruled out thigh edema as a contributing factor.
Given Overend and colleagues' poor success in
validating estimates of thigh cross sectional area
and volume using computed tomography (CT) in
groups of young and old men41 and Sipila and
Suominen's finding of no relationship between
either cross-sectional area or lean tissue to
isometric quadriceps femoris muscle strength
when measured by CT scan and ultrasonography
in 66- to 85 year old female athletes and age-
matched controls42 perhaps our finding is not
surprising. The explanation for this discrepancy
may be two fold. First, changes in intramuscular
fat would not be detectable with the
anthropometric measures used in our study.
Second, changes in neuromuscular recruitment that
may alter mean torque output were not evaluated.
Using the limb without the TKA as a control,
as other Researchers43,44 have done, may
Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013
51
underestimate the magnitude of the deficit in the
limb with the TKA. Jevsevar et all5 suggested that
it may not be appropriate to use the side without
the TKA as a comparison because bilateral OA or
reduced activity consequent to OA may impair
function of the limb without the TKA. The
subjects with TKA had lower peak torque and total
work values for the limb without the TKA
compared with the control subjects. The reduced
muscle performance may be due to continuing
effects of inactivity both before and following
surgery or to nonsymptomatic OA of the knee
without the TKA. Questionnaire responses did not
reveal differences in physical activity between the
control subjects and the subjects who had
undergone TKA. The absence of a difference in
thigh cross-sectional area and estimated muscle
volume suggests that decreased muscle size does
riot explain all of the group differences (Table 2).
Walking and stair climbing have been
identified by clinicians and patients15,45,46 as
critical functional activities. Our findings suggest
that although TKA is very successful in reducing
knee pain (a prime motivation for surgery),
patients are still limited in their functional
activities compared with their age-matched
counterparts. When the normal SPW speed of our
subjects with TKA was compared with the locally
required speed to cross a traffic intersection (1.2
m/ s )47 it became clear that a large proportion of
these individuals (55%, n= 16) must walk at a
faster pace than they normally use in order to
successfully clear the intersection before the light
changes. Indeed even at the fast walking pace,
17% (n=5) of these individuals would not be able
to cross safely at a typical city intersection.
Our analyses suggest that men and women are
affected to differing degrees by TKA. Female
subjects with TKA demonstrated greater
functional limitations on the stair climbing test,
with slower times and increased pain and exertion.
Male subjects with TKA demonstrated smaller
deficits during the stair-climbing test but larger
decreases in muscle strength and local muscular
endurance. Performance on the SPW test at both
normal and fast paces was reduced more in the
female subjects, placing many more of them (62%
at a normal pace and 31% at a fast pace, compared
with 25% and 6%, respectively, for the male
subjects) below the threshold required for safe
crossing of street intersections. Our findings
suggest that data for men and women regarding
walking, stair-climbing performance, and
concentric knee strength and local muscular
endurance should not be pooled.
Pain is a critical aspect of disability due to
OA that can be resolved successfully by surgery.45
One year postoperatively, little pain was reported
in activities such as walking, stair climbing, and
concentric muscle strength testing.29 Yet, in the
relative absence of pain, physical capacity remains
diminished. The consequences of a diminished
physical capacity are evident in slower walking
speeds and a higher physiological cost demanding
greater exertion during physical activity.
The most serious consequences of reduced
physical capacity may be evident as aging further
reduces the reserve capacity of these individuals.
Adequate reserve capacity is an important factor in
the ability of older adults to maintain their
independence. A rehabilitation program that
focuses on weight reduction and aerobic
conditioning may enhance the ability of
individuals with TKA to perform important
activities such as walking and stair climbing. This
program may benefit patients with orthopedic
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52
problems in the years immediately following the
surgery and, perhaps more importantly, may also
help preserve their reserve capacity and allow
them to maintain functional independence for a
longer period in the future.
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473.
9. FlettJL, Burnham RS, Saboe L.et al. Effect of measurement time and mode on amount of flexion
following total knee arthroplasty. Canadian Journal of Rehabililation. 1992;5:145-149.
10. Kantz M, Harris W, Levitsky K, et al. Methods for assessing condition-specific and generic functional
status outcomes after total knee replacement. Med Care. 1992;30:MS240-MS2.52.
11. Ritter MA. Albohm MJ, Keating EM, et al. Comparative outcomes of total joint arthroplasty.
JArthrqfdnsty. 1995;10:737-741.
12. McGuigan EX, Hozack U'J, Moriarty L, et al. Predicting quality of life outcomes following total joint
arthroplasty. J Arthropla~ty. 1995;l0: 742-747.
13. Kroll MA, Otis JC, Sculco TP, et al. The relationship of stride characteristics to pain before and after
total knee arthroplasty. Clin Orthop. 1989;239:191-195.
14. Berman AT, Bosacco SJ, Israelite C. Evaluation of total knee arthroplasty using isokinetic testing.
Clin Orthq. 1991;271:106-113.
15. ,Jevsevar DS, Riley PO, Hodge MTA. Krebs DE.Knee kinematics and kinetics during locomotor
activities of daily living in subjects with knee arthroplasty and in healthy control subjects. Phys Ther.
1993;73:229-242.
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16. Canadian Standarised Test of Fitness (CSTF) Operations .Manual. 3rd ed. Ottawa, Ontario, Canada:
Fitness and Amateur Sport Canada; 1987.
17. Chumlea WC, Roche AF, Rogers E. Replicability for anthropometry in the elderly, Biol,
1984;56:329-337,
18. Malina RM, Roche AF. Manual Physical Status and Performance in Childhood, Volume 2: Physical
Performance New York, NY: Plenum Publishing Corp; 1983
19. Wilmore JH, Behnke AR. An anthropometric estimation of body density and lean body weight in
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20. Jones P, Pearson P. Anthropometric determination of leg fat and muscle plus bone volumes in young
male and female adults. J Physiol Paris. 1969;294:63-66.
21. Clarkson HM, Gilewich GB. Musculoskeletal Assessment: Joint Range of Motion and Manual
Muscle Strength. Baltimore, Md: U'illianis & Wilkins; 1989: 14.
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CORRESPONDING AUTHOR:
*BPT, MPT-Orthopaedics, Senior Physical therapist, Ahmedabad, Gujarat.
Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013
55
RESPIRATORY PHYSIOTHERAPY IN TRIPLE VESSEL DISEASE WITH
POST CORONARY ARTERY BYPASS GRAFTING SURGERY (CABG)
Shanmuga Raju P (MPT)*, Renkha Rao (MCh), Rajendhra Kumar J (MD), SuryaNaryana
Reddy V (MS)
ABSTRACT
We are presenting a case of 47 years of old female with triple vessel disease and coronary artery bypass
graft surgery. Her complaint was chest pain and shortness of breath since last 5 months. Coronary
angiogram revealed triple vessel disease and she underwent three coronary artery graft surgery on 24th
February, 2013. Second day aftter CABG, she developed dyspnoea, reduced chest expansion and decreased
arterial O2 saturation. She was treated with daily session involving positioning, chest percussion, deep
breathing exercise, manual mobilization exercise and passive and active limb movements. We observed that
receiving chest physiotherapy has significant effect in recovery of post CABG patient after 3 weeks of follow
up. Our aim of case study is to describe effects of respiratory physiotherapy in post operative CABG in
triple vessel disease.
Keywords: Triple vessel disease, Coronary artery bypass grafting, respiratory physiotherapy
INTRODUCTION
India have 29.8 million symptomatic patients
with coronary artery disease (CAD).
Approximately, one sixth of the world population
lives in India (1). Coronary artery bypass graft
(CABG) surgery is challenging for coronary artery
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56
disease. CABG is associated with an occurrence of
pulmonary complications, defined as any
pulmonary abnormality that occurs during the post
operative period (2). A decrease in pulmonary
function is well known after open heart surgery.
Chest physiotherapy is routinely used in order to
prevent or reduce pulmonary complications after
surgery. Post operative treatment includes early
mobilization, change in position, breathing
exercises and coughing techniques (3).
CASE REPORT
A 47 year old female patient was diagnosed to
have triple vessel disease; coronary angiogram
revealed triple vessel coronary artery disease and
was referred to department of cardiothoracic
surgery at Chalmeda AnandRao Institute of
Medical Sciences, Karimanagar on 24th February
2013. Medical history was chest pain and
shortness of breathlessness since last 5 months.
She was known case of type to II Diabetes
mellitus, but no history of hypertension. Coronary
angiogram showed triple vessel disease with left
ventricular dysfunction. She underwent coronary
artery bypass grafts surgery and three grafts were
placed, one graft was placed to obtuse marginal 1
(OM 1), second graft was placed to left anterior
descending artery and third graft was placed to
right coronary artery. She was hemodynamically
stable on first post operative day but on second
postoperative day, she had aspirated gastric
contents and developed hypoxia due to asphyxia.
Her blood pressure was 149/81 mm/Hg, pulse
106 per/minute, heart rate 123 per/minute,
respiration rate 16 breaths per/minute, and
temperature was 1000 F. Complete blood picture
show hemoglobin 6.5 gm/cumm, WBC 5,800
cells/cumm, neutrophils 78%, lymphocytes 17%,
eosinophils 03%, monocytes 05%, basophilis 00%
and ESR is 30mm/1hours.
Biochemistry: Sodium 136 mmol/L, potassium
4.1 mmol/L, chlorides 106 mmol/L, fasting serum
glucose 103 mg/dL. Urine level is 100ml. Blood
group is ‘O’ negative. Chest expansion
measurements were 58 cm at axilla level, 83 cm at
nipple level and, 79 cm at xiphoid level.
Figure: 1 Before CABG and respiratory
physiotherapy transthoracic 2D echo cardiogram
show decrease Left ventricular systolic function
(LV ejection fraction (EF) 20.3 %).
Figure: 2 After CABG and respiratory
physiotherapy transthoracic 2D echocardiogram
show improve LV systolic function (LV ejection
fraction 55.3 %).
DISCUSSION
Patient undergoing cardiac surgery (CS), in
most number of cases post operative pulmonary
Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013
57
dysfunction developed with a significant reduction
in lung volume, respiratory function, and lung
compliance and increased work of breathing (4-5).
Atelectasis and hypoxemia are among the main
pulmonary complications post operatively of
CABG (6). Respiratory therapy is often used in the
prevention and treatment of post operative
complications as retention of secretions, atelectasis
and pneumonia (7).
In our case, before CABG, an
electrocardiogram shows Q wave in V1 V2 V3 &
V4 chest lead are poor progression of R wave in
chest lead V5 and V6. After CABG ‘Q’ wave are
present in V1 and V4 chest lead, no new ST- T
changes. Before surgical procedures transthoracic
2D echocardiogram shown normal valves and
normal size chambers. Anterior wall, lateral wall,
anteroseptal wall and apical part of LV were
hypokinetic and reduced LV systolic function.
Second day after surgical procedure (CABG) she
had aspirated gastric contents and developed
hypoxia due to asphyxia. Three week after
respiratory physiotherapy treatment, her chest
expansion, arterial O2 saturation and cardiac
function were improved (EF 55%). She was
discharge and advised follow-up.
CONCLUSION
Our case report showing that post operative
respiratory physiotherapy is an effective
management for a patient with coronary bypass
graft surgery for reducing in pulmonary
complications.
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58
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CORRESPONDING AUTHOR:
*Dr. P. Shanmuga Raju, MPT, Asst. Professor & I/C Head, Department of Physical Medicine &
Rehabilitation, Chalmeda Anand Rao Institute of Medical Sciences, Karimngar- 505001, Andhra Pradesh,
INDIA. E-mail: shanmugampt@rediffmail.com
Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013
59
OCCUPATIONAL THERAPY MARKETING INDIAN PROSPECTIVE
Koushik Sau*
ABSTRACT
OBJECTIVES: The purpose of this study is to find out the present scenario of occupational
therapy marketing in India. METHODOLOGY: An author designed survey questionnaire is used
for this study. Other Allied health staff, other rehabilitation staff and local occupational therapist
revised the questionnaire in three stages. After the three-staged revision final survey questioners
was made and send to different occupational therapist working in various parts of India.
RESULT: All participants (100%) are agreeing with that there is a need of marketing. But they
are not satisfied with the present marketing scenario of occupational therapy in India.
CONCLUSION: This study can use by practitioner for marketing guidance
KEYWORDS: Occupational Therapy, Marketing, Health Care Marketing, Occupational Therapy
Marketing.
1. INTRODUCTION
According to the American marketing
association “Marketing is the process of
planning and executing the conception,
pricing, promotion and distribution of ideas
services and goods, to create exchanges that
satisfy individual and organizational
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objectives”[1] Simply “marketing consists of
meeting people’s needs in the most efficient
and therefore profitable manner”(marketing
OT Services, 1984, p.4) [2] . Marketing can
use as medium of orientation which makes
satisfying the customer’s requirements [2].
Marketing beings by asking what are the
requirements and desires of consumers [3].
Marketing also includes the analysis of the
competition and then decide on a positioning
plan for the product or service, in other words
finding the market position, the pricing of the
products and services, and then promote the
products or services through continue
advertising, promotions, public relations and
sales.
1.1 Health care marketing
Marketing programs sale everything in
today’s life including health care. Though it
was once thought to be inappropriate or
unethical to use in health care professional [2].
According to Willard and Spacksman (1993)
health care marketing evolved in the middle of
1970 when concerns arose about increased
regulation of health care, decrease resources,
increased struggle for those inadequate
resources and change in reimbursement
practice for health care [3].
The health care market is one of the most
complicated one because health care
professional always face a challenge with
different necessities for same kind of
diagnosis. After each diagnosis there are
requirement of various treatments planning
according to demographic charter, political
and regulatory system, socio cultural status,
economical and geographical background [2].
With each variation basic aim is to improve
client’s health through preventive action or
restoration of good health from a state of ill
health.
Management of health care is becoming
more and more common as the demands of
cost containment are placed on providers of
care [4]. In this regards marketing can help
health care profession. Because it is an
important aspect of service delivery that all
health cares practitioners should understand it
[5]. Of course, there is no denying that using
health information in order for healthcare
marketing does run the risk of invades
privacy. Some time people thought that health
care marketing carelessly handled their
sensitive information. In fact, sometimes
health care marketing might cause shameful
offenses to a person's sense of independence
and self-respect. During marketing health care
professional should consider this aspect.
1.2 Present occupational therapy marketing
scenario in India
As occupational therapy professional we
should focused on the marketing for profit of
our profession. Because all of our best efforts
over more than fifty years the profession still
largely unknown to the general public and our
referral sources. Only providing good service
is not enough to grow as a profession. It needs
Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013
61
marketing strategies to develop knowledge
and faith on our profession.
In India the health care services generally
regulated by state government and have rights
to select service area for normal population. In
nineteenth century scenario changed and
private sector started to deliver health service
and person starts to pay for treatment.
Changing scenario society has placed increase
responsibility to consumers in concerning to
their own health care choice. Challenges are
increasing for the occupational therapy
professional and necessary to undertake some
marketing strategies that help them to develop
awareness about occupational therapy services
and there benefits.
Consumer goes through relative reference
about the outcome of different treatment
options. They rely on different information
which are getting from different source like
mouth of patient, service provider, and referral
sources etc. Marketing help occupational
therapy profession to aware those resources
through valuable information. In India many
individuals and organization have been putting
significant effort into creating ways to
increase the visibility and awareness of our
profession but there is a lack of collective
work. Efforts in individuals label are not
enough to overcome barriers of marketing.
Present scenario is not good for occupational
therapy professions in India they understand
the need but don’t know how to market the
profession or don’t bother to spent time for
marketing. This study is a primary effort to
find out the present scenario of occupational
therapy marketing in India and find out the
possible procedure of occupational therapy
marketing in India through open ended survey
questioner.
1.3 Research question
What is the present scenario of
occupational therapy marketing in India?
What are the possible procedures of marketing
occupational therapy in India?
1.4 Objectives of the study
Find out the present scenario of
occupational therapy marketing in India.
Find out the possible occupational therapy
marketing procedure.
2. MATERIAL & METHOD
2.1 Subject:
Occupational therapist graduate were
included for these study. Interns and
student were excluded from this study.
2.2 Survey questioner:
2.2.1 Questioner development:
An author’s design survey questioner was
used for this study [6], [7]. Questions were
definite, concrete and pre-determined,
structured and open ended subjective
question [7]. Same wording and ordering
are maintained for all target people[7].
Three steps were taken to modify the
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question for final study. First these
questions were provided to five allied
health professional . In second stage these
questioner were provided to different
rehabilitation staff, After getting their input
about the clarity of the questioner such as
the wording of the questioner, grammar
usage, simplicity of questions and case of
understand [6],[8] was incorporated to
revise the initial draft of the questioner and
a revised survey was generated. In third
stage revised questioner were send to five
local occupational therapists. Those
occupational therapists were asked to
complete the questioner and provide
comments and suggestion. Comments and
suggestion from the participant’s
occupational therapist were examined by
the investigator and incorporate those into
the revision of the questioner.
2.2.2. The final version of questioner
Final version of questioner consisted two
parts (see appendix). First part concerned
about personal details about participant.
Second part of questioner was consisted of
twelve questions. It concerned about the
different aspect of occupational therapy
marketing procedure to frame the possible
guideline.
2.2.3. Implementation procedure
Survey type research study generally use
large number of sample, because the
percentage of respond generally less 20 to
30 percentages [6],[7] . The survey was
mailed to six hundred occupational
therapist throughout India After getting all
the responses from respondents thank
giving mailed was send to each participant
separately.
3. RESULT:
3.1 Natures of respondents:
Total 137 (22.83 %) response were
received. Not included 16 responses for
not matching the inclusion criteria. Total
121 (20.16%) responds were included for
this study. Charterstic of respondents was
provided in table 1.
Table 1 : Charterstic of respondent (N= 121)
3.2 Nature of respond:
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63
All participants (100%) are belief that
they are not satisfy with the present scenario
of occupational therapy profession in India.
All were belief that after fifty years
occupational therapy not captured enough
market in Indian Allied health field.
Almost all participants (114) are not
presently flowing nitch marketing strategies.
Only few (7) participants are following nitch
marketing style.
All participants are agreed in the
point that we are able to fulfill the need sets of
consumer to capture rehabilitation market
place. In case of fifth question respondents
responds was different. According some
respondents (67) All India Occupational
Therapist (AIOTA) is responsible for
marketing our profession. Some respondents
(30) belief it is a responsibility of AIOTA and
ACOT. Few respondents (7) belief AIOTA
brunches, occupational therapy institution
should take the responsibility. In the other
hand some respondents (15) belief it is a duty
of an individual’s occupational therapist. Two
( 2) respondents belief government or
government health policy are the responsible.
Every respondents are belief that our
profession should be promoted and they
suggested different method for that like
formation of own council, awareness through
media, pass the information through simple
and lay man’s word. Most of the
respondent’s(111) belief is that, surveys is
necessary for occupational therapy marketing.
A few numbers of respondent’s (10) belief that
it may not be useful.
There are mix responses about marketing
style. According to response individuals
marketing and group marketing both is useful
for occupational therapy profession. Most of
the respondents (112) are thought that there
should be change in present marketing style in
context of present health care environment.
Some respondents (9) are not sure the change
is require or not in present marketing style.
According to most respondents belief
electronic media is the best option for
promoting occupational therapy profession in
India. But other beliefs that print media can be
also is another option. Respondent’s belief
that, well documentation of profession is
needful for marketing.
There are so many variation is found in
the response of last question. Respondents
suggested that advertisement should be
publishes in regular basis. Awareness came,
spatial clinic, speech by occupational therapist
in local language is also help in occupational
therapy marketing. Videotapes, documentary
film can be use to promote our services, our
occupational therapy achievement. Physician
awareness also can be use as a technique
because still date they are the main referral for
our services. Some suggested there should be
one liner to promote our profession.
4. DISCUSSIONS
Key finding of this study is that every
participant is not satisfied about present
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marketing scenario of occupational therapy
after fifty years as a profession. Though there
are differences in there beliefs, marketing is
necessary for occupational therapy in present
health care scenario. Without this a profession
can grow.
We know there are no ideal strategies for
marketing occupational therapy in India.
Because India is country of diversity in terms
of culture, language, religious. But there
should be some guidance about marketing,
which can help a professional to capture large
market.
Through this study tried to cover most of
the component of marketing in India through
12 questions. Respondent’s provided there
view point regarding that. In twenty first
century marketing is an important aspect of
any profession. Gradually marketing becomes
common practice in health care profession
also. This study gathered information about
marketing can use to market our profession in
India.
First strength of this study we use
structure question to gather information from
sample so there is no chance of interview bias.
Second, this study collected data from various
parts of country through email so it is low cost
procedure and easily approach to occupational
therapist over India.
Mail were send six hundred occupational
therapist in India. So this result cannot be
generalized. Last limitation is respondents
rate was (22.83 %).
5. CONCLUSION:
In India occupational therapists are either
private practitioner or working in private
sector. There a few numbers of people are
working in government sector. So most of the
time we have to prove as a better treatment
option compare to other profession. In this
regard we can use marketing for survival. This
study can help professional in marketing
occupational therapy profession in better way.
6. ACKNOWLEDGEMENT
I want to thanks to our entire respondent
for their valuable support. I also thanks to
everyone, who helped me to reevaluate
questioner for developed final version of
questioner.
REFERENCES
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2. Jacobs K: Marketing Occupational therapy. American journal of Occupational Therapy, 1987:41:5,
315-320
Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013
65
3. Perinchief J.M: marketing: in service management: in Willard and Spackman’s Occupational
Therapy: 2nd edition:Philadelphia, J.B. lippincote company,1993:396-398
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APPENDIX
Personal details:
Participant Name & Designation:
Age & Sex:
Qualification:
Organization name & Experience (in terms of year):
Clinical experience/ teaching experience:
Marketing questionnaires.
1) Are you satisfied with the present marketing scenario of occupational therapy profession in
India?
2) After fifty years as a profession, has occupational therapy captured enough market in Indian
rehabilitation field?
3) According to you our profession is presently following nitch marketing or any other
marketing strategies in India?
4) According to you our profession is able to fulfill need sets of consumer to capture
rehabilitation market place?
5) According to you who are responsible for marketing occupational therapy profession in
India?
6) For marketing of occupational therapy, does it need to be promoted and if yes point out the
methods of that?
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66
7) Is there any need of consumer surveys prior to marketing of the profession?
8) In the present scenario individual marketing or group marketing is essential for
occupational therapy profession in India?
9) According to you with changing health care environment what modification is needed in
the present marketing style?
10) According to you presently which media is effective for promoting occupational therapy
marketing in India?
11) Is there any role of documentation in occupational therapy marketing?
12) According to you how occupational therapy marketing should be done in present situation
in India?
CORRESPONDING AUTHOR:
* Department of Occupational Therapy, School of Allied Health Science, Manipal University, Karnataka,
India. Email: koushiksau@gmail.com
Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013
67
ANNOTATED BIBLIOGRAPHY OF STUDIES W.R.T STATISTICAL
METHODS
Neha Dewan*
“An annotated bibliography is a list of citations to books, articles, and documents. Each citation is
followed by a succinct descriptive summary and evaluative paragraph, the annotation”.
In the present article, we have provided annotated bibliography of studies from rehabilitation science
that are well written with respect to (w.r.t) the statistical methods aspect of the paper. The identified studies
represents a number of statistical topics addressed in the research.
The purpose of present annotated bibliography is to provide the readers about the effective writing
skills for representing results of statistical analysis in their research papers.
The annotated bibliography mentioned below contains a brief statement of the statistical concepts
effectively conveyed in the paper and a quote or two from the paper illustrating the statements which were
found useful.
1. Bastos FN, Vanderlei LCM, Nakamura FY,
Bertollo M, Godoy MF, Hoshi RA, et al. Effects
of Cold Water Immersion and Active Recovery
on Post-Exercise Heart Rate Variability. Int J
Sports Med. 2012; 33: 873–879.
Participants : “20 young male subjects (age:
21±2 years; height: 175±8 cm; body mass: 72±11
kg; body mass index: 23.5±2.1 kg·m − 2; VO2max:
47.1±3.1 mL·kg − 1·min − 1) were recruited for the
study.”
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Results: “Also, significant differences in the
time required to reach [Lac]peak were found
between CWI and PR (6.3±2.4 vs. 9.8±3.1 min,
respectively) as well as between AR and PR
(7.13±2.71 vs. 9.84±3.07 min, respectively)
(p<0.05, for all)”
� This can be a good example of the use of
descriptive statistics in describing study
participants as well as summarising the results.
2. Lewis JS, Wright C, Green A. Subacromial
impingement syndrome: the effect of changing
posture on shoulder range of movement. J Orthop
Sports Phys Ther. 2005;35:72-87.
Introduction: “The null hypotheses for this
investigation was that changing posture would
have no effect on shoulder range of movement in
asymptomatic subjects and on shoulder range of
movement and pain in subjects with SIS.”
� This can be a good example of clearly
stating Null Hypothesis.
3. Rhon DI, Boyles RE, Cleland J, Brown DL.
A manual physical therapy approach versus
subacromial corticosteroid injection for treatment
of shoulder impingement syndrome: a protocol
for a randomised clinical trial. BMJ. 2011; Jan
1:1(2).
Methods: “The calculations were based on
detecting a 12-point difference in the SPADI with
a standard deviation of 10 points, a two-tailed test
and an α level = 0.05. This generates a sample
size of 43 subjects per group. Allowing for a
conservative dropout of approximately 20%, we
will recruit 104 subjects into the study. This
sample size will yield greater than 80% power to
detect both statistically significant and clinically
meaningful changes in the other outcome
variables. Sample-size estimation was performed
with G*Power software, V 3.1.2.”
� This can be a good example of Sample size
calculation as authors have provided the
information required for sample size calculation
in terms of Zα, Zβ, minimal clinical important
difference(δ), standard deviation(σ) and level of
significance(α). Further efforts are made in
calculating sample size by taking ‘anticipated
drop out’ into consideration.
4. Barreca SR, Stratford PW, Lambert CL, et
al. Test-retest reliability, validity, and sensitivity
of the Chedoke Arm and Hand Activity
Inventory: a new measure of upper-limb function
for survivors of stroke. Arch Phys Med
Rehabil. 2005;86:1616–1622.
Results: “The ICC(2,1) was .98 (95% confidence
interval [CI], .96 –.99). The SE of measurement
was 2.8 CAHAI points (95% CI, 2.3–3.7)”
� This can be a good example of
representation of Test retest reliability as
authors have reported ICC with 95% CI and
standard error.
5. Maly MR, Robbins SM, Stratford
PW, Birmingham TB, Callaghan JP. Cumulative
knee adductor load distinguishes between healthy
and osteoarthritic knees–A proof of principle
Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013
69
study. Gait Posture. 2012 Sep 17.pii: S0966-
6362(12)00318-9.
Results: “The variances of CKAL were unequal
for the two groups. The independent samples t-
test [t = 3.97, df = 51, p = 0.001] revealed that
CKAL was nearly two times larger in the OA
group (80.80± 44.54 kNm s) compared to the
healthy control group (42.79± 28.10 kNm s).”
� This can be a good example of Independent
sample-t test showing comparison of 2
independent samples using t value with degrees
of freedom and level of significance.
6. Wong OM, Cheung RT, Li RC. Isokinetic
knee function in healthy subjects with and
without Kinesio taping. Phys Ther Sport. 2012
Nov;13(4):255-8.
Results: “There was no significant difference in
extension peak torque with and without KT and at
different angular velocities (F(2,28) = 0.24, p =
0.79). Similarly, there was no significant
difference in flexion peak torque in different
conditions (F(2,28) = 0.16, p = 0.86).”
� This can be a good example of Repeated
measures of ANOVA as authors have reported F
value with degrees of freedom and level of
significance.
7. Fernández-de-las-Peñas C, Pérez-de-Heredia
M, Brea-Rivero M, Miangolarra-Page JC.
Immediate effects on pressure pain threshold
following a single cervical spine manipulation in
healthy subjects. J Orthop Sports Phys Ther.
2007;37:325-9.
Results: “Post hoc analysis revealed that the
manipulative procedure produced a greater
increase of PPT in both elbows as compared to
placebo or control interventions (P<.001), and no
significant changes were found after the placebo
or control conditions (P>.6).”
� This can be a good example of presenting
the conclusions of Post hoc analysis and use of
box plots.
8. Rana Jaber, David J. Hewson, Jacques
Duchêne. Design and validation of the Grip-ball
for measurement of hand grip strength. Medical
Engineering & Physics. 2012;34(9):1356–61.
Results: “A linear relationship between the two
readings can be observed (r = 0.997; 95%
confidence interval 0.995–0.998, p < 0.05). The
linear relationship between the pressure recorded
by the Grip-ball sensor and the Vigorimeter
manometer was calculated as:
Grip-Ball Sensor = 0.999 x Vigorimeter
Manometer + 0.533 (1). The coefficient of
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70
determination was calculated as R2 = 0.994 (p <
0.05).”
� This can be a good example of Correlation
and Regression analysis where relationship has
been reported clearly by r value within 95% CI
and .05 as the level of significance. In addition,
relationship has been presented mathematically
using regression model and percentage of
relationship has been expressed by R2.
9. Djordjevic OC, Vukicevic D, Katunac L,
Jovic S. Mobilization with movement and
kinesiotaping compared with a supervised
exercise program for painful shoulder: results of a
clinical trial. Journal of manipulative and
physiological therapeutics. 2012 Jul;35(6):454–
63.
Results: “Because there were frequencies less
than 5, we regrouped ultrasound findings into 2
categories and applied Fisher exact P. There was
no statistically significant difference in ultrasound
findings between the 2 groups (Fisher exact, P =
.4209)”
� This can be a good example of Categorical
analysis where expected frequencies are less than
5 in which case Fisher exact P gives the exact
probability of obtaining the results.
10. Cromie JE, Robertson VJ, Best MO. Work-
Related Musculoskeletal Disorders in Physical
Therapists: Prevalence, Severity, Risks, and
Responses. Phys Ther. 2000;80(4):336-51.
Results: “Male therapists had increased odds of
reporting neck symptoms (OR=1.9, 95% CI=1.3–
2.9), wrist symptoms (OR=2.0, 95% CI=1.3–3.2),
and thumb symptoms (OR=2.2, 95% CI=1.5–3.4)
in the last year compared with their female
colleagues.”
� This can be a good example of Odd’s ratio
showing the association between gender and
prevalence of work related musculoskeletal
disorders.
CORRESPONDING AUTHOR:
* MPT, PhD Student, School of Rehabilitation sciences, McMaster University, Hamilton, ON. Email:
dewann@mcmaster.ca
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